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TUMORS  OF  THE  CEREBELLUM 

CHARLES  K.  MILLS,  M.  D.  ' 

CHARLES  H.  FRAZIER,  M.D. 

GEORGE  E.  DE  SCHWEINITZ,  M.  D. 

T.  H.  WEISENBURG,  M.D.  .'•'''" 

EDWARD  LODHOLZ,  M.  D 


Reprinted  from  the 

New  York  Medical  Journal  and  Philadelphia  Medical  Journal 

for  February  ii  and  i8,  1905 


NEW  YORK: 

A.  R.  Elliott  publishing  company 

66  West  Broadway 
1905 


a,  X 


Copyright,  1903,  by  A.  R.  Elliott  Publishing  Co. 


TABIvE  OF  CONTENTS 

1.  The  Diagnosis  of  Tumors  of  the  Cerebellum,  Espe- 

cially with  Reference  to  Their  Surgical  Removal. 
By  Chari^es  K.  MiIvI,s i 

2.  Remarks  Upon  the  Surgical  Aspects  of  Tumors  of 

the  Cerebellum.     By  Chari^ES  H.  FraziER     .     .     39 

3.  Cases  Illustrating  the  Papers  of  Dr.  Mills  and  Dr. 

Frazier 86 

4.  The  Ocular   Symptoms  of  Cerebellar   Tumors.     By 

George  E.  de  Schweinitz 119 

5.  The   Pathology   of  Cerebellar   Tumors.      By  T.   H. 

WEisEneurg 135 

6.  The   Functions  of  the  Cerebellum.      By  Edward 

IvODHOLZ 171 

ILLUSTRATIONS 

Fig.  I.  Vertical  section  of  head,  showing  the  compara- 
tively small  cavity  in  which  the  cerebellum 
is  contained  and  its  inaccessibility  ....     38 

"     2.     A  head  rest  that  may  be  used  to  advantage  in 

operations  upon  the  head 47 

' '  3.  Photograph  of  a  horizontal  section  of  the  head 
cut  on  a  level  with  the  external  auditory 
meatus 61 

"  4.  Operation  for  the  combined  exposure  of  one 
cerebellar  hemisphere  and  the  occipital  lobe 
of  the  cerebrum 66 

"  5.  Operation  for  the  simultaneous  exposure  of 
both  cerebellar  hemispheres,  necessitating 
ligation  of  the  occipital  sinus 67 

Fig.  I.     Sarcoma  in  left  cerebellopontile  angle      .     .     .    144 

"  2.  Fibroma  compressing  the  lateral  lobe  of  the 
cerebellum  and  the  lower  surface  of  the  tem- 
poral lobe 152 

"     3.     Fibroma  compressing  the  lower  surface  of  the 

cerebellum  and  the  left  side  of  the  pons    .     .155 


THE   DIAGNOSIS   OF  TUMORS   OF   THE 
CEREBELLUM  AND  THE  CEREBEL- 
LOPONTILE       ANGLE,       ESPE- 
CIALLY  WITH   REFERENCE 
TO     THEIR     SURGICAL 
REMOVAL. 

By  CHARLES  K  MILLS,  M.  D., 

PHILADELPHIA, 

PROFESSOR     OF     NEUROLOGY,     UNIVERSITY     OF     PENNSYLVANIA; 

NEUROLOGIST   TO   THE   PHILADELPHIA    GENERAL    HOSPITAL. 

In  time  it  is  probable  that  as  regards  tumors 
of  the  cerebrum,  especially  those  located  on  its 
lateral  aspect  anywhere  from  the  cephalic  tip  to 
the  occipital  pole,  success  both  in  diagnosis  and 
in  operative  treatment  will  reach  from  twenty- 
five  to  fifty  per  cent.  By  success  is  meant  the 
exact  localization  and  removal  of  tumors,  the 
operation  from  the  surgical  point  of  view  being 
entirely  successful,  and  partially  so  from  the  point 
of  view  of  the  removal  of  the  disease.  Supposing 
that  fifty  per  cent,  of  such  cases  are  reached,  ten 
to  fifteen  per  cent,  will  not  recur,  or  at  least  not 
in  periods  varying  from  three  to  ten  years.  In 
the  remainder  the  painful  and  distressing  general 
symptoms  of  brain  tumor  will  be  removed  for  a 


time,  the  neoplasms  recurring  in  some  cases  after 
an  interval,  while  in  others  the  cases  may  termi- 
nate fatally.  Life  in  most  instances  will  not  only 
be  prolonged,  but  will  be  made  much  more  com- 
fortable. Tumors  of  the  mesal  aspect  and  of  the 
base  of  the  brain  will  always  be  uncertain  in  re- 
sult, although  an  occasional  growth  situated  on 
the  orbital  or  temporal  surface  may  be  success- 
fully reached.  We  must,  therefore,  after  growths 
located  on  the  lateral  aspect  of  the  cerebrum,  look 
to  tumors  of  the  cerebellum  and  cerebellopontile 
angle  for  our  next  highest  percentage  of  successes 
in  spite  of  the  hitherto  unsatisfactory,  and  in  some 
instances  even  disheartening,  results  of  surgical 
procedure. 

The  surgical  aspects  of  the  subject,  including 
the  methods  and  results  of  operation  and  statisti- 
cal details,  will  be  fully  considered  by  Dr.  Frazier ; 
but  as  I  have  had  much  experience  in  observing 
operations  on  the  cerebellum,  I  may  be  permit- 
ted, in  introducing  a  discussion  of  the  symptom- 
atology and  diagnosis  of  cerebellar  tumors,  to 
say  a  few  words  about  the  accessible  sites  for 
operation. 

Although  an  operation  is  difficult  and  often  un- 
successful, tumors  in  certain  cerebellar  locations 
may  be  regarded  as  "operable."  These  are:  i. 
Tumors  situated  wholly  or  in  large  part  in  one 


lateral  lobe.  2.  Tumors  situated  upon  or  in  part 
invading  the  vermis  or  middle  lobe.  3.  Tumors 
of  the  cerebellooblongatopontile  angle.  Only  in 
the  case  of  a  tumor  located  in  large  part  in  one 
lateral  lobe  of  the  cerebellum  does  an  operation 
afford  a  really  good  chance  for  success,  but  in  rare 
cases  both  tumors  of  the  vermis  and  of  the  cere- 
bellobulbar  angle  can  be  reached  and  removed. 

With  regard  to  tumors  of  the  vermis  or  mid- 
dle lobe,  the  writer  has  had  no  personal  experi- 
ence with  operative  procedure.  I  believe,  how- 
ever, that  in  some  instances  tumors  resting  upon 
or  even  invading  the  vermis  may  be  reached  and 
removed.  The  operation  in  this  case  should  in- 
clude an  opening  on  each  side  of  the  median  line, 
and  possibly  the  ligation  of  the  sinus  and  the  re- 
moval of  the  bone  intervening  between  the  two 
openings.  Such  an  operation  is  feasible,  al- 
though, perhaps,  difficult. 

The  diagnosis  of  the  existence  of  a  tumor  in 
the  cerebellum  is  as  a  rule  comparatively  easy, 
but  to  exactly  locate  and  infer  the  size  and  ex- 
tensions of  such  a  growth  is  a  more  difficult  task ; 
and  yet  when  operation  for  removal  of  the  tumor 
is  under  discussion,  the  focal  diagnosis  becomes 
of  paramount  importance. 

In  the  first  place,  brief  consideration  will  be 
given  to  general  symptomatology  and  diagnosis. 


In  a  large  majority  of  cases  of  cerebellar  neo- 
plasm the  well  known  general  symptoms  of  brain 
tumor,  namely,  headache,  nausea,  and  vomiting, 
optic  neuritis,  and  vertigo,  are  present  and  are  of 
pronounced  character. 

While  the  headache  in  many  cases  is  intense, 
and  in  some  even  agonizing,  in  others  it  is  of 
moderate  severity  and  in  rare  instances,  of  which 
a  few  have  come  under  my  observation,  it  may 
be  entirely  absent  or  it  may  not  appear  until  late 
in  the  course  of  the  disease.  In  about  half  the 
cases  the  headache  is  referred  to  the  back  of  the 
head  or  to  this  region,  and  at  the  same  time  to 
other  parts,  as  to  the  nape  of  the  neck  and  va- 
rious portions  of  the  cranial  vault.  Frontal  head- 
ache of  a  severe  type  is  occasionally  observed  in 
cases  of  cerebellar  tumor,  just  as  in  some  in- 
stances of  frontal  neoplasm  the  pain  is  most  in- 
tense or  is  present  alone  in  the  occipital  region. 
Too  much  stress  therefore  must  not  be  placed  on 
the  site  of  the  pain. 

Nausea  and  vomiting  are  symptoms  of  fre- 
quent occurrence,  although  they  occasionally  dis- 
appear for  long  periods  in  the  progress  of  a  case. 
The  mechanism  of  these  symptoms  is  much  the 
same  as  that  of  the  vertigo  due  to  dural  irrita- 
tion, which  will  presently  be  considered. 

With  regard  to  optic  neuritis  and  its  conse- 


quences,  it  is  only  necessary  to  say  that  our  ex- 
perience is  similar  to  that  of  others  who  have 
found  this  sign  of  intracranial  tumor  more  con- 
stant in  cerebellar  tumors  than  in  those  located 
in  almost  any  other  region  of  the  brain.  The 
development  of  the  choked  disc  or  optic  neuritis 
is  often  rapid,  or  at  least  goes  on  at  a  much  ac- 
celerated pace  after  it  has  reached  a  certain  mod- 
erate height.  The  choking  of  the  disc  is  extreme, 
and  haemorrhages  are  numerous.  Unless  opera- 
tive interference  checks  the  progress  of  the  in- 
flammation, blindness  speedily  occurs,  and  this  is 
one  of  the  reasons  for  early  surgical  procedure, 
even  when  the  case  has  not  a  hopeful  outlook 
as  regards  removal  of  the  growth. 

Dr.  de  Schweinitz,  in  his  paper  on  the  ocular 
phenomena  of  tumors  of  the  cerebellum,  to  which 
the  reader  is  referred,  fully  considers  the  oph- 
thalmoscopic appearances  and  conditions  in  this 
affection.  Nearly  all  the  cases  included  in  the 
series  from  which  the  inferences  contained  in  this 
paper  are  drawn  were  seen  by  him. 

The  vertigo  which  is  so  frequently  a  general 
symptom  of  brain  tumor,  wherever  situated,  is 
usually  due  to  irritation  of  branches  of  the  tri- 
geminal nerve,  which  are  distributed  near  the 
inner  surface  of  the  dura,  the  irritation  of  the 
fifth  nerve  beins:  reflected  to  the  bulbar  nuclei  of 


this  nerve  and  thence  to  the  pneumog-astric  nu- 
cleus. This  is  usually  one  of  the  causes  of  the 
vertigo  in  tumors  of  the  cerebellum  when  the 
growth  is  connected  with  the  dura,  which  is  not 
the  rule.  In  other  cases  it  should  be  regarded 
as  a  focal  rather  than  as  a  general  symptom  of 
cerebellar  tumor,  as  it  is  caused  by  the  disturbing 
influence  exerted  by  the  tumor  upon  the  cere- 
bellovestibular  apparatus. 

A  distinction  must  always  be  made  between 
cerebellar  vertigo  and  cerebellar  ataxia,  although 
the  two  are  often  so  interblended  that  this  is  not 
easily  done.  Subjective  vertigo  is  common,  the 
patient  usually  describing  it  as  a  feeling  of  dizzi- 
ness. Both  subjective  and  objective  vertigo  may 
be  extreme  and  exhibit  striking  characteristics 
which  indicate  their  focal  origin.  In  a  case  re- 
corded by  Osborne,^  for  example,  in  which  a  large 
glioma  was  situated  in  the  right  cerebellar  lobe, 
the  patient  was  unable  to  sit  up,  and  could  not 
turn  her  head  without  having  an  attack  of  ver- 
tigo. The  dizziness  was  relieved  by  complete 
rest  in  bed,  but  came  on  again  with  less  fre- 
quency, although  with  much  severity.  The  pa- 
tient would  always  lie  with  her  head  to  the  right, 
saying  that  she  became  dizzy  if  it  were  turned 

1  Osborne,  O.  T.,  Journal  of  Nervous  and  Mental  Diseases. 
N.  Y.,  Vol.  xxix,  October,  1902. 


to  the  left.  Later  epileptoid  seizures  took  the 
place  of  the  vertigo. 

I  shall  discuss  next  the  strictly  focal  symp- 
toms of  tumor  of  the  cerebellum. 

Nystagmus  is  one  of  the  most  frequent  symp- 
toms of  cerebellar  tumor.  It  is  present  in  growths 
variously  situated  in  the  cerebellum  or  jointly 
in  the  cerebellum  and  adjacent  parts,  as  for  in- 
stance in  the  middle  lobe,  in  one  lateral  lobe  when 
the  neoplasm  is  close  to  its  junction  with  the 
middle  lobe,  in  the  prepeduncle  or  jointly  in  this 
and  the  oblongata.  A  tumor  or  other  lesion  con- 
fined to  the  flocculus  is  said  to  give  rise  to  nystag- 
mus. The  nystagmus  of  cerebellar  or  cerebello- 
pontile  disease  may  be  of  various  types,  as  re- 
gards the  manner  of  its  occurrence,  its  direc- 
tion, and  the  rapidity  or  slowness  of  the  oscilla- 
tions. It  may  be  present  when  the  eyes  are  quiet 
and  looking  straight  forward,  or  under  these  cir- 
cumstances it  may  be  absent,  but  capable  of  be- 
ing elicited  by  having  the  eyes  turned  either  to 
the  right  or  to  the  left,  or  upward  or  downward. 
It  may  be  horizontal  or  vertical  or  both  in  the 
same  case.  The  movements  are  sometimes  rapid 
and  fine  or  slow  and  comparatively  coarse.  In 
the  case  of  Bruce  referred  to  later  in  this  paper, 
the  nystagmoid  movements,  which  were  present 
in  all  positions,  were  increased  on  lateral  move- 


ments;  on  looking  to  the  right  the  oscillations 
were  slower  and  larger.  They  were  of  inter- 
mediate rapidity  and  extent  in  looking  upward 
or  downward.  It  has  been  suggested  that  the 
nystagmus  can  be  brought  out  when  it  is  not 
present,  or  that  it  is  greater  if  present,  when  the 
eyes  are  turned  toward  the  side  of  the  lesion,  a 
view  which  was  supported  by  one  case  of  cere- 
bellar abscess  recorded  by  Spiller,^  but  was  not 
confirmed  by  a  case  of  cerebellar  tumor  reported 
by  this  writer  in  the  same  paper.  We  have  not 
been  able  as  yet  to  make  any  inferences  of  local- 
izing value  from  a  study  of  cerebellar  nystagmus, 
although  it  would  seem  probable  that  in  a  case 
of  destructive  lesion  affecting  the  cerebellovesti- 
bular  tract,  the  nystagmus  would  be  greater  when 
the  eyes  were  directed  toward  the  side  of  the 
tumor.  I  shall  refer  presently  to  the  views  of 
Bruce  on  this  subject. 

The  question  of  the  existence  of  a  true  paresis 
or  paralysis  as  the  result  of  a  cerebellar  lesion  is 
one  that  has  been  discussed  both  by  physiologists 
and  clinicians.  That  a  general  paralysis  has 
been  observed  as  both  the  result  of  experimental 
lesions  of  the  cerebellum  and  of  cerebellar  haem- 
orrhage, tumor,   or   abscess   in   man   cannot  be 

*  Spiller,  W.  G.,  Amer,  Jour,  of  the  Med.  Sciences^  February, 
1904. 


doubted,  but  in  many  cases  at  least  this  symp- 
tom is  due  to  the  effect  of  the  lesion  on  neighbor- 
ing parts,  as  for  instance  on  the  pyramidal  tract 
or  tracts.  Asthenia  or  muscular  weakness  is, 
however,  a  real  cerebellar  symptom.  Sometimes 
it  is  overlooked,  the  symptoms  which  are  depend- 
ent upon  this  weakness  being  attributed  to  inco- 
ordination or  other  cause. 

In  a  valuable  paper  by  Grainger  Stewart  and 
Gibson^  these  writers  report  at  length  their  obser- 
vations with  regard  to  the  state  of  voluntary 
movements  in  the  five  patients  which  form  the 
basis  of  their  paper.  In  all  of  these  cases  the 
patients  exhibited  weakness  of  the  legs,  as  tested 
not  only  in  standing  and  walking,  but  also  by 
movements  in  bed.  Weakness  of  the  spinal  mus- 
cles was  present  in  three  cases.  Niemeyer,  Hugh- 
lings  Jackson,  and  Risien  Russell,  who  are  cited 
by  Stewart  and  Gibson,  have  shown  that  paresis 
or  weakness  of  the  spinal  or  trunkal  muscles  re- 
sults from  cerebellar  lesion.  Jackson  believes 
that  destructive  lesion  of  the  vermis  causes  pa- 
ralysis or  paresis,  most  marked  in  the  muscles 
of  the  trunk,  next  in  the  lower  extremities,  and 
least  in  the  upper  limbs.  Discussing  the  weak- 
ness of  the  spinal  muscles,  Stewart  and  Gibson 

2  Stewart,  T.  Grainger,  and  Gibson,  G.  A.,  Edinburgh  Hospi- 
tal Reports,  Vol.  v,  Edinbnrgh  and  London,   1898. 


10 

referred  to  the  relief  which  is  sometimes  afforded 
by  the  use  of  crutches.  In  several  cases  of  tumor 
of  the  cerebellum  I  have  observed  distinct  evi- 
dences of  weakness  of  the  muscles  supporting  the 
vertebral  column.  It  is  probable  that  some  of 
the  difhculty  experienced  by  the  patients  in  main- 
taining their  equilibrium,  and  some  of  the  tend- 
ency to  fall  or  pitch  to  one  side  or  the  other,  are 
dependent  in  part  at  least  upon  asthenia  or  pare- 
sis rather  than  entirely  upon  incoordination.  In 
Case  V  of  the  series  appended  to  this  article  and 
that  of  Dr.  Frazier  the  general  musculature  was 
flaccid,  and  the  head  showed  a  tendency  to  fall 
backwards  or  a  little  to  one  side,  apparently  be- 
cause of  weakness  of  the  supporting  muscles  of 
the  neck. 

Batten*  has  called  attention  to  what  he  believes 
to  be  the  diagnostic  value  of  the  position  of  the 
head  in  cases  of  cerebellar  disease.  He  refers 
to  the  fact  that  Risien  Russell  has  observed  in 
animals  after  ablation  of  a  cerebellar  hemisphere, 
that  the  head  sinks  on  the  shoulder  on  the  side 
on  which  the  operation  is  performed,  the  eyes 
being  deviated  to  the  same  side  and  upward,  and 
the  chin  to  the  opposite  side.  The  spinal  col- 
umn is  concave  on  the  side  of  the  ablation.  Bat- 
ten observed  a  case  of  tubercle  of  the  right  lateral 

*  Batten,  T.  E.,  Brain,  Part  101,  Spring,  1903. 


11 

lobe  of  the  cerebellum  in  which  the  patient's  head 
sank  towards  the  left  shoulder,  the  face  looked 
upwards  toward  the  right  and  the  chin  rotated 
to  the  right.  The  spinal  column,  as  in  animals 
experimented  upon,  was  concave  towards  the 
same  side.  The  same  symptoms  have  been  ob- 
served by  Batten  in  hydrocephalus. 

At  a  meeting  of  the  St.  Louis  Medical  Society 
on  September  17,  1904,  at  which  some  remarks 
were  made  by  the  writer  on  the  diagnosis  of  cere- 
bellar tumors.  Dr.  J.  J.  Putnam,  of  Boston,  spoke 
in  the  discussion  of  a  case  in  which  this  symp- 
tom or  some  modification  of  it  was  present. 

The  symptom  known  as  hemiasynergia,  first 
described  by  Babinski,^  who  believes  it  to  be 
present  on  the  side  on  which  a  cerebellar  tumor 
or  other  lesion  exists,  has  been  sought  for  in  all 
cases  of  cerebellar  tumor  recently  observed,  but 
so  far  it  has  not  been  found  a  reliable  sign  of 
cerebellar  disease.  This  symptom  is  brought  out 
in  the  lower  extremity  by  having  the  patient, 
with  his  eyes  shut,  flex  the  leg  fully  on  the  thigh 
and  the  thigh  on  the  abdomen,  and  then  require 
him  to  extend  the  limb  to  its  full  length.  If  the 
extension  is  done  normally,  the  leg  and  thigh 
movements  are  performed  synchronously  or 
rather  synergically,  but  the  leg  is  first  straight- 

'  Babinskl,  Bevue  neurologique.  May  30,  1902,  p.  470. 


12 


ened  out  and  then  the  entire  limb  is  brought  to 
a  horizontal  position  by  a  second  movement.  I 
have  noted  the  presence  of  this  symptom  in  sev- 
eral cases,  but  in  some  instances  when  shown  at 
one  examination  it  would  fail  to  be  elicited  at 
another  in  the  same  extremity.  It  was  present 
on  the  side  of  the  lesion  on  several  occasions 
when  one  of  the  cases  recorded  in  connection  with 
this  paper  was  examined.  On  other  occasions 
the  limb  was  extended  synergically.  Shortly 
after  eliciting  the  sign  at  an  examination  made  in 
the  ward  of  the  hospital,  this  patient  was  taken 
before  the  class  in  the  amphitheatre  and  hemia- 
synergia  could  not  be  demonstrated.  In  the  case 
of  Spiller,  several  times  referred  to  in  this  paper, 
it  was  present  on  the  side  of  the  tumor  and  was 
observed  by  the  writer. 

As  is  said  elsewhere,  a  tumor  circumscribed  to 
the  outer  part  of  one  lateral  lobe  may  not  give 
rise  to  any  symptoms,  or  at  least,  to  any  of  diag- 
nostic value.  Excepting  cases  of  this  kind,  all 
tumors  of  the  cerebellum  cause,  or  at  least  may 
cause,  incoordination.  Some  grade  of  ataxia  has 
been  present  in  all  cases  of  cerebellar  tumor  stud- 
ied by  me.  The  degree  and  character  of  .this 
ataxia  have  varied  greatly  in  different  cases.  It 
is  always  present  in  tumors  of  the  vermis,  unless 
it  may  be  in  cases  to  which  Bruce  has  referred, 


13 

in  which  a  symmetrical  distribution  and  slow 
development  of  the  tumor  prevent  the  appearance 
of  the  ataxia.  The  Romberg  symptom  is  practi- 
cally always  present,  but  it  may  differ  greatly 
in  degree.  It  differs  from  the  static  ataxia  of  a 
case  of  advanced  tabes  in  that  it  is  much  less 
markedly  increased  by  closing  the  eyes.  The 
sway  is,  however,  usually  somewhat  increased 
with  the  eyes  shut;  but  unless  the  cerebellar  dis- 
ease is  much  advanced,  the  patient  will  often  be 
able  to  keep  relatively  steady  on  his  feet  for  a 
considerable  time. 

The  cerebellar  gait  is,  as  it  has  often  been  de- 
scribed, a  staggering  or  titubating  gait.  The 
steps  are  more  irregular  in  their  lateral  and  ver- 
tical amplitude  than  those  of  a  tabetic,  unless  the 
disease  in  the  latter  case  is  advanced  to  a  point 
where  the  patient  can  barely  maintain  himself  in 
the  erect  position  while  walking.  The  pose  and 
the  gait  of  a  case  of  cerebellar  tumor,  or  of  other 
lesions  of  the  cerebellum,  are  due  not  alone  to 
incoordination.  Vertigo  and  muscular  weakness, 
specially  weakness  of  the  muscles  attached  to  the 
spinal  column,  as  well  as  incoordination,  act  in 
their  production. 

The  direction  in  which  the  patient  sways  on 
standing  or  tends  to  pitch  or  fall  in  walking  may 
be    a    matter    of    much    diagnostic    importance. 


14 


Often  it  plays  a  considerable  part  in  the  discus- 
sion of  the  site  of  operation.  According  to 
Starr"  the  staggering  in  four  fifths  of  the  cases 
of  cerebellar  tumor  is  away  from  the  side  of  the 
lesion.  This  is  not  my  own  experience.  In  those 
cases  coming  under  my  observation  in  which 
either  necropsy  or  operation  has  revealed  the 
tumor,  the  swaying  or  staggering  has  been  of- 
tener  toward  the  side  of  the  lesion  than  toward 
the  opposite.  In  two  cases  reported  by  Schede/ 
because  the  patient  tended  to  fall  toward  the  left, 
the  tumor  was  located  on  the  right,  and  in  both 
cases  an  operation  showed  that  it  was  situated 
on  the  left.  In  one  of  these  cases  the  tumor 
could  have  been  successfully  removed.  In  sev- 
eral cases  of  which  the  writer  has  personal  knowl- 
edge the  focal  diagnosis  was  wrong  as  to  the  side 
on  which  the  operation  was  performed,  although 
we  should  certainly  have  the  data  to  enable  us  to 
avoid  this  mistake — one  which  is  not  made  by 
skillful  diagnosticians  with  regard  to  any  other 
region  of  the  brain,  unless  it  is  occasionally  the 
prefrontal. 

In  discussing  this  question  of  the  side  of  the 
cerebellum  on  which  a  lesion  is  situated,  as  de- 
termined by  a  study  of  the  symptomatology  of 

*  Ktarr,  M.  A.,  Orgmrtie  Nervous  Diseases,  1903,  p.  612. 
'  Schede,  Deutsche  med.  Wochenschr.,  July,  1900,  No.  30. 


15 

the  case,  it  should  first  be  borne  in  mind  that  one 
half  of  the  cerebellum  exerts  its  influence  on  the 
same  side  of  the  body  as  itself,  its  action  on  the 
spinal  cord  being  direct  and  not  crossed.  Bruce 
has  so  well  presented  the  facts  which  should  guide 
us  in  determining  the  side  on  which  a  tumor  is 
situated  that  I  shall  take  the  liberty  of  present- 
ing his  views,  founded  as  they  are  upon  both  close 
pathological  and  clinical  investigation. 

The  limits  of  a  paper  intended  to  be  chiefly 
clinical  will  not  permit  me  to  present  at  length 
the  facts  and  arguments  of  this  article,  one  of 
the  most  valuable  contributions  to  cerebellar  lo- 
calization of  recent  years.  I  shall,  however,  sum- 
marize a  few  of  its  most  salient  points. 

The  cortex  of  the  vermis  contains  the  termini 
of  at  least  six  different  tracts  from  the  spinal  cord. 
Bruce^  holds  that  the  direct  cerebellar  tract  and 
the  anterolateral  tract  of  Gowers,  which  go  to 
the  cortex  of  the  middle  lobe,  are  afferent  to  the 
cerebellum.  One  tract  from  the  nucleus  of  Dei- 
ters  passes  downwards  into  the  anterolateral  col- 
umn of  the  spinal  cord ;  another  tract  sends  fibres 
to  both  the  sixth  and  the  third  nuclei.  The  first 
of  these  tracts,  which  has  been  given  the  name 
of  the  vestibulospinal  tract,  has  been  traced  to 

8  Bruce,  Alexander,  Trcma.  of  the  Edinl).  MetlAco-OMrurg^cal 
8oc.,  January,  1899. 


16 


the  lowest  part  of  the  thoracic  cord,  and  gives  off 
fibres  to  the  anterior  cornua,  these  distributions 
being  to  the  same  side  of  the  spinal  cord  as  the 
nucleus.  The  third  connection  of  Deiters's  nu- 
cleus is  with  the  roof  nucleus  of  the  middle  lobe 
of  the  cerebellum.  This  tract  is  efferent.  The 
cortex  of  the  middle  lobe  of  the  cerebellum  is  con- 
nected by  sagittal  fibres  with  the  roof  nuclei. 

The  dentate  nucleus  is  the  chief  seat  of  origin 
of  the  prepeduncle,  fibres  passing  by  wa)^  of  the 
prepeduncle  to  the  red  nucleus  and  the  thalamus. 
This  nucleus  being  partly  in  the  middle  and  part- 
ly in  the  lateral  lobes,  a  tumor  situated  deeply 
enough  to  invade  it  or  fibres  passing  from  it  to 
the  prepeduncle  will  cause  disturbance  of  equi- 
libration of  a  peculiar  kind. 

"  We  may  expect,"  says  Bruce,  "  disturbances 
of  equilibrium  to  be  produced  by  symmetrical 
lesions  situated  within  an  area  bounded  by  the 
intracerebellar  path  of  the  two  inferior  peduncles, 
of  the  two  superior  peduncles,  and  the  dentate 
nuclei,  in  which  the  latter  arise.  This  area  con- 
tains the  middle  lobe  (superior  and  inferior  ver- 
mis, the  roof  nuclei,  and  the  sagittal  fibres  con- 
necting the  latter  with  the  cortex),  and  the  cere- 
bellovestibular  tracts  from  the  roof  nuclei  to  the 
nucleus  of  Deiters.  Lesions  within  this  area  may 
produce  no  such  disturbances,  provided  they  are 


17 

symmetrically  situated  with  reference  to  the  me- 
sial plane,  and  especially  if  their  growth  is  so  slow 
that  compensation  is  established  pari  passu  with 
the  disturbances  they  may  tend  to  cause.  On  the 
other  hand,  lesions  situated  in  the  lateral  lobes 
may  produce  no  disturbance  of  equilibrium,  pro- 
vided they  are  situated  entirely  external  to  the 
intracerebellar  paths  of  the  upper  and  lower 
peduncles  and  of  the  nucleus  dentatus  (area  of 
possible  latency).  If,  however,  these  structures 
are  interfered  with,  either  by  pressure  or  by  di- 
rect involvement,  then  the  characteristic  symp- 
toms of  cerebellar  disease  will  be  produced,  and 
will  depend  in  their  character  and  amount  on  the 
nature  and  extent  of  this  interference.  If  the 
cerebellovestibular  tract,  or  Deiters's  nucleus,  be 
injured,  then  the  usual  stimuli  will  not  pass  either 
to  the  anterior  cornua  of  the  cord  or  to  the  sixth 
(fourth)  or  third  nuclei.  Hence  may  result  the 
weakness  of  the  same  side,  the  tendency  to  fall 
to  that  side,  the  impairment  of  the  conjugate  dev- 
iation to  that  side,  the  tendency  of  both  eyes  to 
be  directed  to  the  opposite  side,  and  the  lateral 
nystagmus  which  occurs,  especially  when  the 
eyes  are  directed  towards  the  same." 

In  what  is  here  said  the  tumor  is  regarded  as 
acting  destructively,  but  if  it  acts  as  an  irritative 
lesion  it  may  cause  rigidity  or  spasm  of  the  same 


18 


side,  with  a  tendency  to  fall  toward  the  opposite 
side,  the  eyes  being  turned  to  the  same  side  by 
irritation  of  the  sixth  nucleus  of  that  side. 

It  may  be  asked.  How  is  one  to  determine 
whether  the  tumor  is  acting  as  an  irritative  or  a 
destructive  lesion?  The  answer  to  this  should 
be  found  in  a  study  of  the  spastic  or  non-spastic 
condition  of  the  limbs  of  one  side,  and  a  careful 
consideration  of  the  side  to  which  the  eyes  are 
turned. 

In  the  case  of  Dr.  Spiller,  which  was  operated 
on  by  Dr.  Frazier,  the  patient  tended  to  always 
pitch  or  fall  toward  the  right,  and  the  tumor  was 
found  at  necropsy  on  this  side.  The  same  was 
true  of  several  cases  observed  by  me. 

Bruce,®  in  a  second  paper,  has  recorded  a  case 
of  cerebellar  tumor  in  which  the  principles  of 
localization  as  taught  in  his  first  paper,  were  suc- 
cessfully put  into  practice.  In  this  case  the 
ataxic,  asthenic,  and  ocular  symptoms  pointed  to 
the  left  side,  the  patient  pitching  towards  the  left. 
The  tumor  was  found  on  this  side. 

The  diagnosis  of  a  tumor  confined  to  the  mid- 
dle lobe  is  relatively  easy,  and  has  already  been 
indicated  in  the  references  just  made  to  the  two 
articles  by  Bruce. 

» Bruce,  Alexander,  Scottish  Medical  and  Surgical  Journal, 
September,  1899. 


19 


In  one  of  three  cases  recorded  by  Preston^°  a 
tumor  of  the  vermis,  probably  "  operable,"  was 
revealed  by  necropsy.  This  case  exhibited  abo- 
lition of  the  muscular  sense  (?)  in  both  arms 
and  leg-s,  with  inability  to  stand  or  walk  and  a 
tendency  to  always  fall  backward,  never  to  either 
side.  Necropsy  showed  a  bilobar  tumor  com- 
pressing the  vermis  like  a  saddle  in  its  inferior 
part.  It  also  exerted  some  compression  upon 
the  quadrigeminum ;  it  apparently  had  attach- 
ments to  the  callosum,  falx,  and  tentorium. 

While  all  the  facts  necessary  for  final  decision 
regarding  the  effects  on  the  brain  of  the  direc- 
tion of  movement  of  lesions  situated  in  different 
parts  of  the  vermis  are  not  yet  at  our  command, 
it  is  probable,  as  usually  taught,  that  destruction 
of  the  cephalic  portion  of  the  vermis  will  cause  a 
tendency  to  fall  forwards  and  irritation  a  tend- 
ency to  fall  in  the  opposite  direction ;  while  de- 
struction of  the  caudal  portion  will  cause  a  tend- 
ency to  fall  backwards,  and  irritation  will  bring 
about  the  muscular  adjustment  necessary  to  coun- 
teract this  tendency.  It  has  already  been  shown 
that  destructive  lesion  involving  the  lateral  lobe 
and  vermis  or  that  part  of  the  lateral  lobe  con- 
taining portions  of  the  cerebellovestibular  and 
cerebellospinal  mechanisms  causes  a  tendency  to 

10  Preston,  Alienist  and  Neurologist,  St  Louis,  April,  1892. 


20 

sway  or  fall  to  the  side  of  the  lesion  an  irritative 
lesion  bringing  about  the  opposite  result. 

In  connection  with  these  discussions  of  the 
direction  of  movement  as  symptom  of  cerebellar 
tumor,  it  is  probable  that  the  lesions  more  often 
act  as  destructive  than  as  irritative  factors. 

Physiologists,  as  the  results  of  their  experi- 
ments upon  animals,  have  frequently  observed 
spasticity  or  rigidity.  In  some  cases  curvatures 
of  the  body,  apparently  the  result  of  spastic  con- 
ditions, have  taken  place.  In  some  clinical  re- 
ports spasticity  and  contractures  are  set  down 
as  among  a  comparatively  common  phenomena 
of  cerebellar  tumor. 

Retraction  of  the  head  and  neck,  opisthotonos, 
and  general  tetanic  rigidity  have  been  recorded. 
In  the  experience  of  the  writer  tonic  spasms  and 
contractures  are  very  rare  in  tumors  strictly  lim- 
ited to  the  cerebellum.  I  have,  however,  seen 
these  symptoms  associated  with  hydrocephalus 
and  in  cases  in  which  the  tumor  has  invaded  parts 
outside  of  the  cerebellum,  as  for  instance,  the 
oblongata  or  pons.  When  present,  the  tonic  spas- 
ticity may  be  on  the  side  of  the  lesion  or  on  the 
opposite  side.  The  spasticity  may  be  a  transient 
symptom.  It  has  never  proved  of  diagnostic  im- 
portance in  my  studies  of  cerebellar  disease. 

One  reason  for  the  difference  between  the  re- 


21 


ported  results  of  lesions  of  the  cerebellum  experi- 
mentally produced  and  the  effects  of  tumors  re- 
sides in  the  fact  that  the  former  immediately  and 
for  a  long  time  are  irritative  phenomena,  while 
the  latter,  owing  to  their  usually  slow  growth, 
produce  their  effect  by  inhibition,  pressure,  and 
destruction. 

The  asthenia,  atonia,  and  astasia  which  Luciani 
so  strongly  emphasizes  as  the  chief  effects  of 
destructive  lesions  of  the  cerebellum  experiment- 
ally produced  are  well  illustrated  by  clinical  facts. 
The  case  of  cerebellar  tumor  is  asthenic,  although 
not  paralyzed,  is  atonic  or  flaccid  rather  than 
spastic,  and  is  astatic  or  incoordinate.  The  ex- 
tent and  position  of  his  asthenia,  atonia,  and 
astasia  depend  upon  the  extent  and  location  of 
the  lesion. 

While  clonic  spasm  is  an  infrequent  local  symp- 
tom of  cerebellar  tumor,  it  is  occasionally  ob- 
served. In  a  case  recorded  by  Spiller,  which 
was  seen  by  the  writer  in  consultation,  the  patient 
had  at  times  fine  twitching  movements  of  the 
right  extremities,  although  at  times  the  move- 
ments were  on  both  sides  of  the  body. 

Tremor,  especially  of  the  head  and  upper  ex- 
tremities, has  been  recorded  as  one  of  the  results 
of  physiological  experiment  on  the  cerebellum. 
It  occurs  in  a  large  percentage  of  the  cases  of 


32 

cerebellar  tumor,  and  was  a  notable  symptom  in 
one  or  two  of  the  cases  seen  jointly  by  Dr.  Frazier 
and  the  writer. 

My  experience  indicates  that  the  muscular 
sense  is  not  lost  in  cases  of  cerebellar  disease. 
The  patient  may  be  ataxic  as  well  as  asthenic  and 
atonic,  and  yet  on  testing  him  carefully  for  the 
muscular  sense  or  its  components,  the  so  called 
senses  of  pressure,  weight,  posture,  location,  etc., 
these  are  not  affected.  Grainger  Stewart,  and 
Gibson  carefully  tested  the  muscular  sense  and 
found  it  unaffected  in  their  five  cases.  Others 
have  recorded  the  loss  of  muscular  sense  in  cere- 
bellar lesions,  but  as  a  rule  without  any  details, 
and  it  is  a  question  in  these  cases  whether  the 
loss  of  muscular  sense  has  not  been  confounded 
with  other  manifestations,  such  as  ataxia.  Stere- 
ognostic  perception  is  also  unaffected  in  tumors 
and  other  lesions  of  the  cerebellum. 

In  a  series  of  cases  appended  to  the  papers  of 
Dr.  Frazier  and  the  writer,  the  muscular  sense, 
stereognostic  perception,  and  all  forms  of  cuta- 
neous sensibility  were  studied,  but  with  negative 
results,  except  in  one  instance  in  which  a  doubt- 
ful cutaneous  hypsesthesia  was  present.  When 
impaired  sensation  in  the  distribution  of  the  fifth 
nerve  is  present  in  cerebellar  disease  it  is  prob- 
ably an  indirect  or  pressure  symptom.     I  am  not 


23 


speaking  now  of  cases  of  tumor  of  the  cerebello- 
pontile  angle,  in  which  the  fifth  nerve  or  its  roots 
may  be  directly  implicated.  The  cerebellum  is 
above  all  a  motor  organ  ;  its  most  distinctive  focal 
symptoms,  vertigo,  ataxia,  asthenia,  and  nystag- 
mus being  affections  of  motility. 

A  few  words  might  be  said  in  this  connection 
about  the  diagnosis  of  cerebellar  neoplasms  from 
tumors  of  one  or  two  other  regions  of  the  brain. 

Tumors  situated  in  one  lateral  lobe,  but  invad- 
ing deeply  so  as  to  involve  the  cerebellovestibular 
apparatus  and  perhaps  the  vermis,  may  need  to 
be  dififerentiated  from  tumors  of  the  superior 
parietal  region.  The  chief  diagnostic  points  in 
favor  of  the  tumor  being  cerebellar  are  the  ab- 
sence of  astereognosis  and  that  of  symptoms 
showing  the  loss  or  disturbance  of  muscular  or 
cutaneous  sensibility.  Nystagmus  as  a  rule  is 
not  present  in  parietal  tumors,  although  this  is 
a  rule  not  without  exception,  especially  if  the 
tumor  should  extend  far  enough  backward  to  in- 
volve the  visual  motor  region  of  the  cerebral  cor- 
tex. Vertigo  may  be  present  in  a  parietal  tumor, 
but  the  peculiar  and  extreme  form  of  vertigo 
which  has  been  described  as  due  to  disturbance 
of  the  cerebellovestibular  tracts  and  centres  is 
not  observed  in  parietal  cases.  These  cases  are 
generally  more  distinctly  unilateral  in  their  symp- 


24 

toms,  although  unilaterality  is  occasionally  quite 
marked  in  cerebellar  tumors.  The  invasion  symp- 
toms of  parietal  tumor  will  help  in  diagnosis. 

Tumors  of  the  cerebellum  need  occasionally  to 
be  differentiated  from  prefrontal  growths.  This 
diagnosis  is  difficult  only  when  the  tumor  is  con- 
fined to  the  external  portion  of  one  lateral  lobe, 
so  that  the  symptoms  given,  such  as  ataxia  and 
nystagmus,  are  not  marked  or  are  not  present  at 
all.  I  have  seen  but  little  of  the  frontal  ataxia 
of  Bruns ;  so  little  indeed  as  to  make  me  doubt- 
ful of  its  existence  as  a  true  ataxia.  The  symp- 
tom when  present  is  probably  a  pseudoataxia  due 
to  the  impaired  mentality  of  the  patient  in  conse- 
quence of  which  his  powers  of  attention  and  in- 
hibition are  so  affected  that  he  does  not  govern 
his  movements  quite  normally.  When  a  prefron- 
tal growth  is  situated  on  the  left,  mental  symp- 
toms of  a  distinctive  character  are  present,  these 
being  absent  in  cerebellar  growths.  The  cere- 
bellar patient  is  often  feeble  in  pursuing  his  men- 
tal processes,  which,  however,  are  in  themselves 
quite  clear.  If  the  prefrontal  tumor  invades 
backward,  aphasia,  agraphia,  and  unilateral  mo- 
tor paralysis  may  ensue. 

As  indicated  when  discussing  the  subject  of 
nystagmus,  disorders  of  ocular  movements,  and 
especially  of  associated  movements,  are  among 


25 

the  most  frequent  symptoms  of  cerebellar  dis- 
ease. Various  cranial  nerve  symptoms  are  often 
observed  in  tumor  of  the  cerebellum,  but  these 
are  not  necessarily  present.  They  are  the  result 
either  of  pressure  in  the  case  of  tumors  of  large 
size  and  marked  density  or  of  the  invasion  of  the 
oblongata  and  pons  and  the  nerve  roots  by  tumors 
situated  toward  the  inferior  surface  of  the  cere- 
bellum. I  am  not  speaking  here  of  the  special 
forms  of  tumor  of  the  cerebellopontile  angle,  as, 
for  instance,  those  which  arise  from  the  eighth 
nerve,  but  of  growths  which  originate  in  the 
cerebellum  proper.  Neural  symptoms  when 
present  are  of  much  importance  in  questions  of 
focal  diagnosis  and  of  prognosis;  in  the  former 
in  deciding  the  side  on  which  the  lesion  is  sit- 
uated, in  the  latter  by  pointing  to  a  less  favorable 
outcome  than  when  the  neoplasm  is  confined  to 
the  substance  of  the  cerebellum. 

The  nerve  symptonis  may  be  referable  to  any 
of  the  cranial  nerves  or  their  connections  from 
the  third  to  the  twelfth.  Among  the  most  fre- 
quent are  those  indicating  paralysis  or  paresis  of 
associated  ocular  movements,  paresis  of  the  mus- 
culature supplied  by  the  sixth  or  the  seventh 
nerve,  impairment  of  hearing  from  implication 
of  the  cochlear  portion  of  the  eighth  nerve,  dis- 
orders of  taste  due  to  involvement  of  the  glosso- 


26 


pharyngeal  or  chorda  tympani,  and  loss  or  per- 
version of  sensation  because  of  trigeminal  dis- 
turbance. The  nerves,  their  roots,  or  the  tracts 
with  which  they  are  connected  in  the  oblongato- 
pons  may  be  involved  separately  or  conjointly. 
When  the  neural  symptoms  are  due  to  pressure 
they  are  probably  usually  to  be  referred  to  direct 
nerve  or  nerve  root  involvement.  While  uni- 
lateral symptoms  may  point  to  true  nerve  impli- 
cation, this  distinction  is  by  no  means  a  sufficient 
one,  as  tumors  of  the  cerebellum  not  infrequently 
involve  jointly  one  lobe,  one  peduncle,  and  one 
side  of  the  oblongata  or  pons. 

Among  the  pontooblongatal  pressure  symp- 
toms which  may  result  from  a  cerebellar  tumor 
are  hemiparesis  and  vasomotor,  cardiac,  and  res- 
piratory disturbances.  Convulsions,  unilateral 
or  general,  but  more  commonly  the  latter,  with 
unconsciousness,  have  occurred  in  a  considerable 
percentage  of  the  cases  which  have  come  under 
my  observation. 

With  our  present  knowledge  and  views  regard- 
ing the  anatomy  and  physiology  of  the  cerebral 
olfactory  apparatus,  it  is  at  times  difficult  to  de- 
termine how  loss  of  smell,  which  is  common  in 
cerebellar  tumors,  is  produced.  In  some  cases  it 
may  originate  in  much  the  same  way  as  optic 
neuritis  and  blindness  occur,  that  is,  from  neural 
inflammation  or  from  nerve  choking. 


27 


With  regard  to  the  deep  reflexes,  little  that  is 
of  value  in  focal  cerebellar  diagnosis  is  as  yet 
at  our  command.  We  have  observed  the  knee 
jerks  lost,  exaggerated,  crossed,  and  differing  on 
the  two  sided  either  as  regards  loss,  impairment, 
or  increase.  Unilateral  differences  are  sometimes 
of  corroborative  value  when  the  question  of  the 
side  on  which  a  tumor  is  situated  is  under 
consideration.  In  one  of  the  cases  appended, 
for  instance,  the  knee  jerk  was  exaggerated 
on  the  side  opposite  to  that  on  which  the  tu- 
mor was  presumably  situated,  probably  because 
the  neoplasm  exerted  pressure  downward  on  the 
pyramidal  tract  before  its  decussation.  The  Bab- 
inski  response  is  usually  absent,  although  it  was 
present  on  the  side  opposite  the  lesion  in  one 
case.  The  superficial  reflexes  are  usually  un- 
changed. 

Incontinence  of  urine  and  faeces  is  present  in 
a  few  cases  apparently  as  symptoms  referable  to 
the  presence  of  the  tumor.  Such  incontinence  is 
of  course  present  in  cases  of  tumor  of  the  brain, 
no  matter  what  its  situation,  when  the  disease 
has  advanced  to  such  a  point,  or  the  suffering  of 
the  patient  has  become  so  great  that  his  mind  is 
obtunded. 

Other  symptoms  which  have  been  occasionally 


28 

recorded  in  cases  of  tumor  of  the  cerebellum  are 
polyuria,  glycosuria,  and  muscular  wasting. 

In  the  discussion  of  the  papers  of  Bruce  refer- 
ence is  made  to  the  fact  that  tumors  of  one  lateral 
lobe  of  the  cerebellum  may  in  some  instances  not 
give  rise  to  symptoms,  and,  as  indicated  by  Bruce, 
this  is  in  those  cases  of  lateral  lobe  disease  in 
which  the  lesion  does  not  extend  inward  far 
enough  to  invade  the  cerebellovestibular  or  cere- 
bellospinal apparatus.  This  is  not,  however,  the 
only  explanation  of  cerebellar  lesions  without 
cerebellar  symptoms.  In  other  cases  of  very 
slowly  developing  tumors  the  cerebellum  grad- 
ually accommodates  itself  to  the  lesion.  It  is 
well  known  that  cases  both  of  cerebral  and  cere- 
bellar tumors  are  recorded  in  which  the  growths 
have  undoubtedly  been  present  for  many  years, 
and  the  fact  was  ,not  discovered  until  they  were 
unexpectedly  revealed  by  necropsy. 

Bruce,  as  already  indicated,  has  also  called 
attention  to  the  fact  that  a  tumor  symmet- 
rically disposed  as  regards  the  vermis,  ihat 
is  so  developing  as  to  uniformly  implicate 
both  halves  of  the  vermis  and  equally  the 
adjacent  portions  of  the  lateral  lobe  may  not 
cause  miarked  disturbance  of  equilibrium.  Those 
cases  of  tumors  of  parts  adjacent  to  the  cerebel- 
lum,  like  the   quadrigeminum,   for   example,   in 


29 


which  symptoms  are  not  present,  although  ne- 
cropsy seemed  to  show  that  the  cerebellum  was 
markedly  compressed,  can  only  be  explained  on 
the  theory  of  compressed  brain  substance  accom- 
modating itself  functionally  to  the  gradually  de- 
veloping conditions.  The  same  thing  is  observed 
in  a  notable  degree  in  some  cases  of  internal  hy- 
drocephalus in  which,  although  the  brain  is  al- 
most reduced  to  a  shell,  the  cerebral  centres  and 
tracts  continue  to  functionate. 

With  regard  to  cases  such  as  have  been  re- 
corded by  Spiller  and  others,  and  which  are  re- 
ferred to  by  Weisenburg,  in  which  a  large  por- 
tion or  almost  the  entire  cerebellum  has  been 
absent  or  sclerotic,  some  evidences  of  the  lack 
of  cerebellar  influence  will  usually  be  found  on 
close  investigation. 

In  a  series  of  eight  cases,  Nonne  has  reported 
three  cases  which  presented  the  symptoms  of  tu- 
mor of  the  cerebellum.  The  symptoms  of  brain 
tumor  disappeared  either  under  mercurial  treat- 
ment or  spontaneously.  Nonne  believed  that  in 
none  of  them  was  syphilis  present.  Partial  nerve 
atrophy  was  left  in  some  of  the  cases.  Nonne," 
in  his  discussion  of  the  cases,  excluded  such  diag- 
noses as  encephalitis,  meningitis,  abscess,  throm- 

"  NoDBe,  Deutsche  Zeitschrift  fUr  Nervenheilkunde,  Vol.  Ml, 
1904. 


30 

bosis,  multiple  sclerosis,  chlorosis,  nephritis,  in- 
toxications, and  infections,  also  syphiloma  and 
tubercle.  He  also  believed  that  they  were  not 
cases  of  hydrocephalus,  although  he  was  some- 
what doubtful  on  this  point. 

In  two  cases  of  tumor  not  situated  in  the  cere- 
bellum, but  so  located  as  to  obstruct  the  ventricu- 
lar outlets,  hydrocephalus  was  produced  and  the 
symptoms  of  cerebellar  tumor  were  present.  In 
three  other  cases  in  which  no  signs  of  internal 
hydrocephalus  were  present,  cerebellar  symptoms 
were  exhibited.  The  necropsy  in  these  cases 
showed  absolutely  nothing. 

Cases  such  as  these  must  be  borne  in  mind 
when  considering  the  diagnosis  of  a  tumor  of  the 
cerebellum. 

TUMORS    OF   THE    CEREBELLOPONTILE   ANGLE. 

With  regard  to  the  connections  of  the  growths 
with  the  nervous  system,  at  least  two  forms  of 
tumors  are  found  in  the  cerebellopontile  angle  or 
recess,  and  this  fact  should  be  recognized  when 
surgical  procedure  is  contemplated.  In  the  first 
place,  the  tumor  mass  may  involve  the  substance 
of  the  cerebellum  or  one  of  its  peduncles,  and  the 
oblongatopons,  and,  secondly,  the  tumor  may 
originate  in  one  or  two  of  the  cranial  nerves  and 
be  largely  confined  to  them,  the  acoustic  being 


31 

especially  the  seat  of  such  growths.  With  re- 
gard to  tumors  in  both  the  substance  of  the  cere- 
bellum and  of  the  bulb,  many  have  been  put  on 
record  and  several  have  been  seen  by  the  writer. 
In  a  case  of  multiple  sarcomatosis  for  several 
weeks  under  my  care,  and  later  passing  into  the 
hands  of  Dr.  Spiller,^^  who  records  the  case  in 
full  in  a  paper  on  multiple  sarcomatosis,  tumors, 
probably  sarcomatous,  involved  the  nervous  sub- 
stance in  both  cerebellar  recesses,  numerous 
other  tumors  being  present  in  other  regions  both 
of  the  brain  and  spinal  cord.  When  a  tumor  in- 
volves somewhat  deeply  the  substance  of  the 
cerebellum  and  pons,  it  can  only  be  partially  re- 
moved, and  even  to  accomplish  this  it  will  be  nec- 
essary to  assume  considerable  risk,  as  the  opera- 
tion is  both  difficult  and  dangerous.  The  cere- 
bellopontile  tumors  most  amenable  to  operation 
are  the  fibromata  of  the  eighth  nerve,  which  will 
next  be  briefly  considered. 

Besides  reviewing  the  literature  of  the  subject, 
Fraenkel  and  Hunt  have  recorded  five  cases  of 
tumors  of  this  kind  with  necropsies.  With  re- 
gard to  the  particular  nerves  on  which  these  tu- 
mors occur,  they  say  that  "  the  eighth  shows  a 
marked  predisposition  and  is  most  frequently  in- 

"  Spiller  and  Hendrickson,  Am.  Jour,  of  the  Med.  Set.,  Jaly. 
1903. 


32 

volved,  rather  rarely  on  both  sides.  The  trigem- 
inus is  next  in  order.  The  facial  is  believed  by- 
some  to  be  occasionally  the  seat  of  these  tumors ; 
its  proximity  to  the  acoustic  nerve  renders  path- 
ological decision  difficult."  One  point  of  great 
importance  with  regard  to  these  tumors  of  the 
acoustic  nerve  is  their  peculiar  formation,  the 
manner  in  which  they  are  encapsulated  and  the 
ease  with  which  they  can  be  removed  with  opera- 
tion if  they  are  or  become  accessible  through  the 
work  of  the  surgeon.  They  are  usually  oval  or 
rounded  and  vary  in  size,  some  being  as  large  as 
a  hen's  egg.  They  are  attached  to  the  nerve 
trunk,  which  has  undergone  atrophy  because  of 
their  presence. 

The  pathology  of  fibromata  of  the  acoustic  and 
other  cranial  nerves  is  fully  considered  by  Weis- 
enburg. 

Although  an  acoustic  neurofibroma  is  so  close- 
ly related  to  the  brain  stem  as  to  be  within  a  few 
millimetres  of  it,  nevertheless  the  symptoms  of 
bulbar  involvement  may  be  entirely  absent.  This 
has  been  pointed  out  by  von  Monakow,  in  whose 
case  vomiting,  difficulty  in  deglutition,  and  bul- 
bar disorders  of  circulation  and  respiration  were 
entirel}'-  absent.  Von  Monakow^^  indicates  as 
the   best   diagnostic   points   for   a   neurofibroma 

"  Berl.  kUn.  Wochenschr.,  August  13,  1900,  No.  33,  p.  721. 


33 

of  the  acoustic,  the  absence  of  such  symptoms 
as  vomiting,  dysphagia,  etc.,  on  the  one  hand, 
and  on  the  other  hand,  the  presence  of  general 
symptoms  of  cerebral  tumor,  such  as  headache, 
vertigo,  and  choked  discs  in  association  with  cere- 
bellar ataxia,  rapidly  developing  deafness,  pare- 
sis of  the  seventh  and  fifth  nerves  on  the  same 
side  as  the  deafness,  with  associated  ocular  palsy, 
also  on  the  same  side,  dysarthria  and  Gerhardt's 
symptom  being  absent.  In  such  cases  in  addi- 
tion, peripheral  ear  disease  should  be  excluded. 
If  ataxia  is  present,  the  tendency  will  usually  be 
to  deviate  or  fall  tov\rard  the  side  of  the  lesion. 

In  the  five  cases  of  cerebellopontile  nerve 
tumors  reported  by  Fraenkel  and  Hunt,  operation 
was  attempted  in  only  one ;  it  would  probably 
have  been  successful  in  one  or  two  others  if  the 
procedure  had  been  undertaken  at  the  right  time. 
In  the  case  on  which  operation  was  performed 
the  growth  was  nodular,  was  in  the  left  ponto- 
oblongatal  cerebellar  space,  and  was  of  about  the 
size  of  a  hen's  egg.  It  was  broken  up  by  the  in- 
dex finger  and  the  fragments  removed.  The  pa- 
tient died  of  symptoms  pointing  to  central  car- 
diac and  respiratory  disorders. 

Two  cases  of  fibromata  of  the  acoustic,  of 
which  photographic  illustrations  are  given  in  the 
paper  of  Dr.   Weisenburg,  have  recently  fallen 


34 


under  my  observation.  In  one  case  an  operation 
was  performed  over  the  cortical  facial  region  and 
a  lesion  was  found  in  this  position.  The  main 
lesion,  however,  was  undoubtedly  the  tumor  of 
the  cerebellopontile  recess.  The  chief  focal  symp- 
toms were  one  sided  deafness,  tinnitus,  facial 
monospasm,  hypaesthesia  on  one  side  of  the  face, 
nystagmoid  movements,  slight  paresis  of  right 
abducens,  vasomotor  and  cardiac  disturbances ; 
severe  headache,  nausea,  vomiting,  and  optic  neu- 
ritis were  also  present. 

The  fuller  history  of  this  case  is  given  in  the 
paper  of  Dr.  Weisenburg.  The  notes  of  the 
other  case  are  appended. 

In  this  case  a  fibromatous  tumor  of  the  acous- 
tic was  unexpectedly  found  at  necropsy  in  the 
cerebellooblongatopontile  space.  The  record  of 
this  case  is  given  to  show  how  such  a  growth  can 
be  entirely  overlooked.  The  necropsy  revealed 
not  only  the  presence  of  this  tumor,  but  also 
marked  hydrocephalus,  which  may  have  ac- 
counted for  most  of  the  symptoms  presented  by 
the  patient,  such  as  spasticity,  mental  hebetude, 
headache,  and  optic  neuritis,  but  it  was  insuffi- 
cient to  account  for  them  all.  The  patient's  hear- 
ing on  each  side  was  never  positively  deter- 
mined. Examinations  for  any  of  the  special 
senses  were  unusually  difficult  after  she  came 


35 

to  the  hospital,  and  grew  more  and  more  so  as 
days  advanced.  It  is  probable  that  she  had  loss 
of  hearing  on  the  side  of  the  growth. 

The  patient  was  a  woman  forty-eight  years 
old.  The  facts  which  could  be  obtained  regard- 
ing her  history  before  admission  to  the  Univer- 
sity Hospital  were  meagre.  It  was  learned,  how- 
ever, that  three  or  four  years  before  she  had  an 
attack  which  was  supposed  to  be  one  of  grippe, 
and  following  this,  inflammation  of  the  middle 
ear  on  both  sides  accompanied  by  pus,  which  re- 
quired the  membrane  of  the  tympanum  on  the 
right  to  be  opened.  This  history  clouded  the  diag- 
nosis as  regarded  involvement  of  the  acoustic 
nerve  by  intracranial  neoplasm ;  in  addition,  as 
already  stated,  it  was  difficult  to  make  a  care- 
ful examination,  owing  to  her  mental  state. 

It  was  also  learned  from  one  of  her  physicians 
that  two  or  three  years  before  coming  into  the 
hospital  she  had  complained  of  a  feeling  of  cush- 
ions under  her  feet,  and  that  at  this  time  she  had 
some  anaesthesia  of  the  right  side  of  the  face  and 
of  the  right  hand  and  leg.  About  a  year  before 
admission  her  legs  began  to  grow  stiff  and  she 
had  sharp  shooting  pains  in  them.  This  stiff- 
ness increased  and  she  had  some  difficulty  of  gait. 
At  times  she  had  been  troubled  with  double 
vision.  She  had  always  been  a  sufferer  from 
headache,  but  it  was  stated  that  this  had  not  in- 
creased. For  a  year  she  had  had  difficulty  in 
controlling  her  bowels  and  bladder. 

Examination  showed  the  patient  to  be  dull  and 


36 

apathetic.  Her  memory  was  greatly  impaired, 
she  was  easily  confused,  and  it  was  at  times  al- 
most impossible  to  fix  her  attention.  Her  legs 
were  markedly  spastic,  being  flexed  at  nearly  a 
right  angle.  The  Babinski  reflex  was  not  pres- 
ent. The  knee  jerks  were  exaggerated.  The  left 
pupil  was  considerably  larger  than  the  right.  Sen- 
sation was  apparently  everywhere  preserved,  al- 
though it  was  difficult  to  test  for  fine  differences 
in  sensation.  Facial  and  masseter  paralysis  were 
not  present,  and  except  as  above  noted,  the  exam- 
inations, which  were  thoroughly  made,  were  neg- 
ative. An  eye  examination  by  Dr.  de  Schweinitz 
showed  double  choked  discs  and  many  hsemor- 
rhages ;  there  was  no  apparent  muscle  palsy. 

An  operation  was  performed  by  Dr.  Frazier  in 
this  case  for  the  relief  of  her  general  symptoms, 
the  prefrontal  region  being  selected.  The  ven- 
tricle was  reached  a  short  distance  from  the  sur- 
face after  the  trephine  opening  had  been  made. 

Probably  a  diagnosis  could  have  been  made  in 
this  case  if  the  patient  had  been  studied  early 
and  continuously.  Late  in  the  case  the  general 
symptoms  were  those  of  brain  tumor,  but  the  only 
focal  symptoms  which  could  be  clearly  deter- 
mined by  a  study  of  the  case  and  its  history  were 
the  ansesthesia  of  one  side  of  the  face,  and  the 
probable  impairment  of  hearing.  Some  of  the 
symptoms,  like  the  double  spasticity,  parsesthesia 
of  the  feet,  and  sharp  shooting  pains,  seemed  to 
point  to  spinal  disease. 


Fig.  1. — Vertical  section  of  head,  showingthe  comparatively  small  cavity 
in  which  the  cerebellum  is  contained  and  its  inaccessibility.  Note 
the  distance  between  the  cerebellum  and  the  cutaneous  surface  ; 
note  also  the  angle  of  the  tentorium  and  the  position  of  the  lateral 
sinus. 


REMARKS  UPON  THE  SURGICAL  ASPECTS 
OF  TUMORS   OF  THE    CEREBELLUM. 

By  CHARLES  H.  FRAZIER,  M.  D., 

PHILADELPHIA, 

PROFESSOR    OF    CLINICAL    SURGERY^    UNIVERSITY    OF    PENNSYL- 
VANIA;   SURGEON    TO    THE    UNIVERSITY    HOSPITAL. 

ANATOMICAL   CONSIDERATIONS. 

The  difficulties  that  attend  any  attempt  on  the 
part  of  the  surgeon  to  expose,  much  less  remove 
tumors  from  the  cerebellum,  differ  very  materially 
from  those  encountered  in  tumors  of  the  cerebrum. 
Speaking  upon  this  subject  on  another  occasion  I 
said  that  it  seemed  as  though,  in  encompassing  the 
cerebellum  with  such  large  cranial  sinuses,  nature 
has  intimated  that  this  organ  was  never  to  be  sub- 
jected to  exposure  at  the  hands  of  the  surgeon. 
When  one  takes  into  consideration  the  position  of 
the  lateral  and  the  occipital  sinuses  with  relation  to 
the  only  means  of  access  to  the  cerebellum,  and  the 
plane  of  the  tentorium  cerebelli,  one  realizes  at  once 
that  there  are  especial  technical  difficulties  in  sur- 
gical atacks  upon  the  cerebellum.  (See  Fig.  i.)  Fur- 
thermore, it  must  be  remembered  that  there  are  very 
distinct  dangers  attending  manipulations  upon  the 
cerebellum  and  more  particularly,  if,  in  an  attempt  to 
get  sufficient  exposure  to  excise  a  tumor,  one  should 


40 

make  too  much  traction  upon  the  medulla  oblongata. 
Even  when  one  has  removed  a  considerable  portion 
of  the  skull  below  the  superior  curved  line,  there 
will  be  exposed  to  view  but  a  small  portion  of  the 
gross  surface  area  of  the  cerebellum.  Neither  the 
upper  surface,  that  is  in  relation  with  the  tentorium 
cerebelli  nor  the  anterior  surface  which  is  in  rela- 
tion with  the  petrous  surface  of  the  temporal  bone, 
nor  the  mesial  surface  will  be  exposed  to  view  by 
this  procedure ;  whereas  in  the  cerebrum  the  entire 
cortex  and  a  considerable  portion  of  the  base  can 
be  laid  bare  by  a  very  simple  osteoplastic  opera- 
tion. Furthermore  the  cavity  of  the  cerebellum  is 
very  much  smaller  than  that  of  the  cerebrum,  so 
that  there  is  very  much  less  space  in  which  to  con- 
duct the  manipulations  necessary  either  for  ex- 
posure or  removal  of  the  tumor.  In  the  adult  skull 
one  hemisphere  of  the  cerebellum  is  contained  in 
a  cavity  whose  greatest  dimension  is  only  10.5  cm. 
In  addition  to  the  difficulties  that  are  associated 
with  operations  in  a  space  so  small  and  difficult 
of  approach  one  is  hampered  further  by  the  fact  that 
even  under  normal  conditions  the  cerebellar  hem- 
ispheres are  compressed  in  a  relatively  smaller 
space  than  the  hemispheres  of  the  cerebrum,  and 
are  under  such  tension  that  when  tension  is  relieved 
by  the  reflection  of  a  dural  flap  the  cerebellar  tissue 
almost  invariably  protrudes  through  the  opening. 


41 


The  tissues  cannot  be  displaced  or  retracted  neither 
to  the  same  degree  nor  with  as  much  ease  as  can 
the  cerebral  lobes.  Thus  the  operator  will  be  em- 
barrassed in  attempting-  to  expose  a  lesion  deeply 
situated,  as  for  example  at  the  cerebellopontile 
angle,  a  favorite  seat  for  tumors. 

In  addition  to  the  larger  sinuses,  the  lateral  and 
occipital,  certain  tributaries  of  sufficient  size  to 
cause,  when  injured,  profuse  and  sometimes  alarm- 
ing haemorrhage,  penetrate  that  portion  of  the  occi- 
pital bone  which  must  be  removed.  The  most  con- 
stant of  these  is  a  branch  of  the  lateral  sinus  which 
passes  obliquely  through  the  skull  and  appears  in 
the  surface  between  one  and  two  centimetres  to  the 
inner  side  of  the  mastoid  process;  occasionally  one 
or  more  will  be  found  just  below  the  superior  curved 
line  in  the  neighborhood  of  the  occipital  protuber- 
ance. 

The  occipital  bone  overlying  the  cerebellum  is 
very  variable  in  thickness.  In  the  region  of  the 
mastoid  process  and  of  the  occipital  protuberance 
the  bone  is  exceedingly  thick,  but  from  these  two 
processes  the  thickness  of  the  bone  gradually  de- 
creases until  at  a  point  about  midway  between  the 
two  it  will  be  found  comparatively  thin. 

INDICATIONS    FOR   OPERATION. 

In  general  terms  it  may  be  said  that  the  indica- 
tions for  operation  in  cases  of  suspected  tumors 


43 

of  the  cerebellum  do  not  differ  materially  from 
those  which  have  been  endorsed  in  the  treatment 
of  tumors  of  the  cerebrum.  In  both  classes  of 
cases  once  the  diagnosis  has  been  made,  operation 
if  it  is  to  be  performed  at  all,  should  not  be  post- 
poned for  any  length  of  time.  Physicians  are  too 
prone  to  put  off  the  time  indefinitely  almost  and  to 
spend  months  in  the  often  fruitless  administration 
of  antisyphilitics,  or  to  spend  an  unwarrantable 
amount  of  time  in  efforts  to  establish  a  diagnosis 
beyond  a  peradventure  of  doubt,  or  to  localize  the 
tumor  with  mathematical  accuracy.  Kocher  says 
there  should  be  less  delay  in  bringing  to  the  surgeon 
a  lesion  of  the  encephalon,  whether  it  be  a  neoplasm, 
tubercle,  gumma  or  abscess.  "  There  is  no  more 
excuse  to-day  for  delaying  operation  in  cases  of 
tumors  because  the  tumor  could  not  be  exactly  local- 
ized, than  there  would  be  for  declining  to  operate 
upon  a  case  of  intracranial  haemorrhage  because  one 
was  unable  to  determine  positively  the  seat  of  the 
clot.  Failing  in  one  place  to  find  the  tumor,  other 
trephine  openings  may  be  made  or  a  very  extensive 
area  may  be  exposed  by  an  osteoplastic  resection. 
How  often,  Kocher  says,  has  one  trephined  over  the 
anterior  branch  of  the  middle  meningeal  artery  when 
the  autopsy  revealed  the  clot  in  the  region  of  the 
posterior  branch."  The  surgeon  might  come  in 
for  his  share  of  criticism  because  of  his  lack  of 


43 

precise  knowledge  concerning  the  neurological  as- 
pects of  the  disease.  In  order  that  the  very  best 
results  be  obtained  the  internist  and  the  surgeon 
must  work  hand  in  hand  in  this  as  well  as  other 
fields.  In  cases  of  suspected  tumors  of  the  viscera 
an  exploratory  operation  is  now  regarded  as  per- 
fectly justifiable,  and  why?  Because  physicians 
have  come  to  realize  that  if  operation  is  postponed 
until  the  presence  of  the  tumor  can  be  demonstrated 
by  palpation  or  other  means,  the  lesion  is  by  this 
time  so  extensive  that  the  time  for  a  radical  opera- 
tion has  passed.  As  the  exploratory  operation  is 
recognized  as  the  surest,  safest,  and  most  reliable 
diagnostic  measure  in  tumors  of  the  stomach,  it 
should  be  considered  of  equal  value  and  importance 
in  tumors  of  the  brain.  Postponement  of  operation 
should  be  discountenanced  if  for  no  other  reason 
than  because  in  cases  of  long  duration  patients  with 
tumors  of  the  brain  make  very  poor  subjects  for 
operative  intervention ;  the  operation  is  of  itself  one 
of  considerable  gravity  and  the  condition  of  the 
patient  should  be  so  good  as  to  enable  him  to  with- 
stand its  depressing  efifect. 

Unfortunately  tumors  of  the  cerebellum  are  in 
the  majority  of  instances  more  difficult  of  localiza- 
tion than  tumors  of  the  cerebrum  and  in  many 
cases  localization  is  well  nigh  impossible.  Instead 
of  regarding  this,  as  has  been  the  case  so  often,  as 


44 


a  reason  for  delay,  the  difficulty  of  localization 
should  be  considered  rather  as  an  indication  for  an 
early  exploratory  operation.  Just  so  soon  as  the 
diagnosis  is  with  a  reasonable  degree  of  certainty 
assured,  just  so  soon  should  the  operation  be  per- 
formed, providing  other  measures  have  failed  and 
the  operation  per  se  is  not  contraindicated. 

Operation  as  a  Palliative  Measure. — Under  cer- 
tain circumstances  we  despair  of  being  able  to 
perform  a  radical  operation ;  either  the  tumor  can- 
not be  found  or  cannot  be  localized;  it  may  be  in- 
accessible, or  it  may  have  attained  such  proportions 
as  to  make  its  removal  impracticable.  In  any  of 
these  contingencies  a  palliative  operation  is  justifi- 
able and  in  some  cases  should  be  regarded  as  im- 
perative. The  headache,  vertigo,  and  vomiting,  so 
constant  in  cerebellar  tumors,  make  the  life  of  the 
patient  pitiable  and  yet  he  may  be  relieved  of  all 
of  these  symptoms  for  a  considerable  time  by 
adopting  such  measures  as  will  reheve  pressure. 
But  the  strongest  argument  against  delay  of  opera- 
tion in  the  treatment  of  cerebellar  tumors  is  the 
possibility  of  being  able  to  save  the  patient's  vision : 
choked  disc  is  one  of  the  most  constant  symptoms 
and  if  permitted  to  continue  unrelieved  too  long,,  an 
optic  neuritis  will  develop  and  the  time  for  complete 
or  even  partial  restoration  of  vision  will  have 
passed.     Nothing  could  be  more  striking  than  the 


45 

results  of  palliative  operation  in  one  ©f  our  patients 
(Case  4).  The  patient  before  the  operation  suf- 
fered from  intense  headache,  was  almost  blind,  and 
vertigo  was  so  pronounced  that  he  could  not  stand 
without  support.  The  tumor  could  not  be  found 
but  a  large  portion,  perhaps  one  third  to  one  half 
of  one  cerebellar  hemisphere,  was  removed.  His 
headache  was  relieved  at  once,  within  a  week  he 
was  able  to  see  as  he  lay  in  bed  small  specks  on 
the  ceiling,  and  on  getting  up  was  able  to  go  about 
with  but  very  little  instability.  Nothing  could  be 
more  gratifying  to  the  physicians  in  attendance  than 
the  relief  which  was  afforded  the  patient  by  this 
comparatively  simple  procedure.  In  one  of  Krause's 
cases,  after  a  palliative  operation,  the  patient  was 
relieved  of  many  of  the  subjective  disturbances  and 
lived  for  a  period  of  three  years  in  comparative 
comfort. 

Operative  Technique, — Regarding  the  position  of 
the  patient,  it  is  advisable  to  operate  with  his  head 
and  shoulders  considerably  elevated.  This  will 
diminish  the  haemorrhage  to  a  certain  extent.  The 
effect  of  the  elevated  position  upon  the  blood  pres- 
sure may  be  counteracted  by  applying  a  firm  band- 
age to  the  lower  extremities.  In  order  to  afford 
greater  freedom  for  the  necessary  steps  of  the  opera- 
tion, I  use  an  extension — a  very  simple  appliance — 
which  is  easily  attached  to  the  operating  table  and 


46 

upon  which  the  head  rests  (see  Fig.  2).  While 
using  it  in  all  operations  upon  the  brain  I  find  it 
most  serviceable  in  operations  upon  the  cerebellum 
where  the  quarters  are  especially  cramped.  In  two 
operations  upon  the  cerebellum  Schede  placed  his 
patients  in  the  sitting  posture,  leaning  far  forward. 
This  posture,  according  to  Schede,  diminishes  to  a 
considerable  degree  the  haemorrhage,  but  the  posi- 
tion is  a  very  awkward  and  difficult  one  in  which 
to  retain  the  fully  anaesthetized  and  relaxed  patient. 
The  patient  may  be  placed  upon  his  side  but  it  is 
difficult  to  retain  the  patient  in  this  position  and 
there  is  always  the  tendency  of  the  patient  to  roll 
over  on  his  side,  in  which  position  the  respiratory 
act  will  be  embarrassed,  and,  inasmuch  as  many  of 
the  sudden  deaths  are  due  to  respiratory  failure,  it 
is  advisable  to  take  such  precautionary  measures 
as  will  avoid  any  disturbance  of  the  respiration. 

Incision. — The  incision  should  begin  at  the  tip 
of  the  mastoid  process  on  the  affected  side  and 
follow  a  line  parallel  with,  but  one  centimetre  above 
the  superior  curved  line,  to  the  median  line.  From 
this  juncture  a  vertical  incision  may  be  made  down- 
wards to  enable  one  to  reflect  the  flap  sufficiently 
to  expose  the  field  of  operation.  Haemorrhage  from 
the  scalp  in  this  region  is  so  profuse  that  some 
precautions  should  be  taken  to  reduce  to  a  minimum 
the  amount  of  blood  lost.    A  very  excellent  plan  is 


49 

to  incise  but  an  inch  or  an  inch  and  a  half  at  a  time, 
proceeding  at  once  to  arrest  the  haemorrhage  in  one 
section  before  incising  the  next.  Considerable 
bleeding  may  be  prevented  if  one  reflects  the  peri- 
cranium simultaneously  with  the  overlying  muscles 
and  their  attachments.  If  this  precaution  is  taken 
the  muscles  will  not  be  mutilated  to  the  same  extent 
as  would  be  necessary  if  an  attempt  was  made  to 
reflect  them  independently  of  the  overlying  peri- 
osteum. What  may  be  not  only  a  troublesome,  but 
an  alarming  feature  is  the  haemorrhage  from  the 
various  sinuses  that  traverse  the  occipital  bone; 
these  have  already  been  referred  to  in  the  section 
on  the  anatomy.  Suflice  it  to  say  that  one  should 
always  be  prepared  with  suitable  means  for  con- 
trolling the  bleeding  from  this  source,  since  if  un- 
controlled, the  patient  may  lose  in  a  very  short  time 
a  pint  of  blood  or  more.  In  one  of  our  cases  (Case 
5)  two  anomalous  sinuses  almost  as  large  in  diame- 
ter as  a  quill  were  found  near  the  occipital  pro- 
tuberance. Before  the  haemorrhage  could  be 
checked  the  patient  lost  so  large  a  quantity  of  blood 
that  it  was  deemed  advisable  to  suspend  further 
interference  until  the  patient  had  recovered  fully 
from  the  effects  of  this  complication.  Following 
the  administration  of  appropriate  remedies,  the  pa- 
tient reacted  within  a  reasonable  time,  but  about 
twelve   hours    after   the   operation,    suddenly   and 


50 


without  any  warning,  the  cardiac  and  respiratory 
functions  failed  and  within  ten  minutes  the  patient 
was  dead.  Whether  the  loss  of  so  much  blood  had 
anything  to  do  with  the  termination  of  the  case,  is 
a  matter  purely  of  speculation.  This  instance  is 
cited  solely  as  an  illustration  of  what  may  be  a  very 
serious  complication,  namely,  haemorrhage  from 
the  venous  channels  traversing  the  occipital  bone. 
One  should  try  to  control  the  bleeding  first  with 
Horsley's  wax  and  if,  as  in  the  case  above  referred 
to,  this  fails,  the  outlet  of  the  sinuses  should  be 
closed  with  plugs  of  wood,  which  can  be  whittled  to 
the  proper  thickness  and  length  from  ordinary 
swab  sticks. 

There  need  be  no  anxiety  about  the  cranial 
sinuses  as  a  possible  source  of  haemorrhage.  The 
lateral  sinus  is  fully  exposed  to  view  when  the  bone 
has  been  removed,  and  injury  to  this  structure  could 
result  from  carelessness  only.  The  occipital  sinus 
does  not  come  within  the  field  of  operation  unless 
one  intends  to  remove  the  intervening  bone,  in 
which  case  the  sinus  will  be  exposed  to  view,  and  if 
necessary  may  be  ligated  (see  Fig.  5). 

Removal  of  Bone. — With  Krause,  Schede,  and 
others  I  believe  that  it  is  unnecessary  to  preserve 
the  overlying  bone,  therefore,  the  osteoplastic  flap, 
which  has  done  so  much  to  revolutionize  the  surgery 
of  tumors  of  the  cerebrum,  is  not  to  be  employed 


51 

in  the  exploration  of  the  cerebellum.  As  both  V. 
Bergmann  and  Kocher  have  said,  the  muscles  and 
aponeurosis  are  thick  enough  at  this  point  to 
offer  adequate  protection  to  the  underlying  struc- 
tures and  to  make  bony  closure  of  the  opening  un- 
necessary. 

An  opening  in  the  skull  is  made  preferably  with 
a  chisel  at  a  point  about  midway  between  the  occi- 
pital protuberance  and  mastoid  process.  Here  the 
bone  is  comparatively  thin  and  as  Foirier  says  this 
is  the  point  of  greatest  safety.  The  opening  so 
made  is  enlarged  with  rongeur  forceps  in  all  di- 
rections; outwards  as  far  as  one  can  go  without 
opening  the  mastoid  cells,  upwards  until  the  lateral 
sinus  is  entirely  exposed  to  view,  inwards  to  within 
a  centimetre  of  the  median  line,  and  downwards  to 
a  point  at  least  one  centimetre  distant  from  the  fora- 
men magnum.  The  removal  of  bone  will  be  facili- 
tated by  using  rongeur  forceps,  the  blades  of 
which  are  at  an  angle  of  about  65  degrees  with 
the  handles.  As  one  approaches  the  region  of  the 
lateral  and  occipital  sinus,  the  forceps  should  be  laid 
aside  for  a  moment  and  a  dural  separator  intro- 
duced to  separate  the  dura  and  the  sinuses  from 
the  skull. 

I  prefer  the  chisel  to  the  trephine  for  making  the 
initial  opening  for  two  reasons:  first  because  the 
opening  can  be  made  more  rapidly  with  a  chisel, 


52 

and  secondly  because  the  operation  of  a  trephine 
in  this  region  is  a  somewhat  awkward  procedure. 

Exploration. — After  a  dural  flap,  with  its  base 
downwards,  has  been  reflected,  one  proceeds  to 
search  for  the  tumor,  unless  it  has  been  decided  to 
resort  to  the  two  stage  operation.  The  principles 
which  we  have  applied  in  deciding  this  question 
are  precisely  those  which  have  been  adopted  in  our 
operations  for  tumors  of  the  cerebrum  (see  Ameri- 
can Journal  of  the  Medical  Sciences,  February, 
1904).  If,  when  the  preliminary  stages  of  the  opera- 
tion have  been  completed,  the  condition  of  the  pa- 
tient, as  revealed  by  the  blood  pressure  and  pulse 
record,  is  one  of  depression  or  shock,  the  final  stage 
of  the  operation  should  be  postponed  until  the  pa- 
tient has  reacted.  Having  decided  to  continue  the 
operation  the  surgeon  proceeds  to  inspect  and  pal- 
pate the  surface  exposed  to  view.  If  the  cerebellar 
tissues  protrude  considerably  through  the  opening 
once  the  dura  is  incised,  the  presence  of  a  tumor 
or  an  internal  hydrocephalus  should  be  suspected. 
It  should  be  borne  in  mind,  however,  that  under 
normal  conditions  the  cerebellum  is  under  greater 
tension  than  the  cerebrum,  and  when  the  dura  is 
incised  the  normal  cerebellum  w']1  protrude  in  many 
cases  through  the  opening  to  a  slight  degree. 

If  the  clinical  symptoms,  to  which  are  added  the 
presence  of  an  anomalous   condition   revealed  by 


53 

the  sense  of  sight  or  touch,  lead  one  to  believe  the 
tumor  is  situated  in  the  lateral  hemisphere,  the 
subsequent  steps  of  the  operation  should  consist  in 
an  exploratory  incision  into  the  cerebellar  tissue, 
and,  if  the  tumor  is  found,  in  its  complete  extirpa- 
tion. The  impunity  with  which  we  can  freely  in- 
cise the  cerebellar  hemisphere  without  the  risk  of 
such  disturbance  of  function  as  would  follow  a  sim- 
ilar procedure  in  the  motor  area  of  the  cerebral 
cortex  should  be  borne  in  mind.  A  failure  to  find  or 
expose  a  tumor  of  the  cerebellar  hemisphere  because 
of  an  insufficient  exploratory  incision  should  be 
regarded  as  inexcusable  unless  the  tumor  was  of 
very  small  dimensions.  If  on  the  other  hand  there 
is  reason  to  believe  the  growth  is  situated  at  the 
cerebellopontile  angle,  a  favorite  site  for  cerebellar 
tumors,  the  subsequent  steps  of  the  operation  will 
be  attended  with  some  difficulty.  It  may  be  possi- 
ble in  exceptional  cases  with  the  aid  of  a  retractor 
to  displace  the  cerebellar  tissue  sufficiently  to  expose 
the  tumor,  but  in  the  great  majority  of  cases  one 
must  resort  to  one  of  two  methods  to  bring  the  tu- 
mor into  view;  either  a  portion  of  the  cerebellar 
hemisphere  must  be  removed  or  the  ventricles  must 
be  punctured. 

PUNCTURE   OF   THE   VENTRICLES. 

This  procedure  has  been  resorted  to  for  two  pur- 
poses, first  as  a  purely  palliative  measure  to  relieve 


54 


tension  and  again  to  relieve  tension  in  order  to 
render  it  possible  to  make  a  more  thorough  ex- 
ploration of  the  cerebellar  surfaces.  Puncture  of 
the  ventricles  is  unfortunately  an  operation  of  un- 
usual gravity  and  the  danger  attending  it  is  so  great 
in  comparison  to  the  possible  benefit  as  to  make  it 
a  procedure  of  questionable  propriety.  Many  cases 
have  been  reported  in  which  the  results  were  dis- 
astrous. In  one  reported  by  Krause,  a  scalpel  was 
introduced  into  the  lateral  ventricle,  a  drain  intro- 
duced and  about  200  c.c.  of  cerebrospinal  fluid  were 
withdrawn.  The  intracranial  tension  was  relieved 
to  such  a  degree  that  the  operator  was  able  to  see 
the  superior  vermiform  process,  but  the  patient  col- 
lapsed immediately  after  the  fluid  was  withdrawn. 
Heidenhain's  experience  was  equally  disastrous. 
Thinking  he  was  dealing  with  an  idiopathic  hydro- 
cephalus and  that  the  relief  of  pressure  would  have 
a  beneficial  effect  he  tapped  one  lateral  ventricle  and 
the  patient  died  suddenly  on  the  night  of  the  opera- 
tion. Heidenhain  attributed  his  death  to  the  sud- 
den disturbance  of  pressure.  The  operation  has 
been  practised  by  a  number  of  surgeons,  and  in  one 
instance  with  favorable  results,  but  in  the  majority 
of  cases  the  patient  died  immediately  or  soon  after- 
wards. 

LUMBAR   PUNCTURE. 

V.  Bergmann  attributes  the  relief  which  follows 
palliative  operations  for  tumors  of  the  brain  more 


55 

to  the  escape  of  cerebrospinal  fluid  than  to  the  re- 
moval of  a  large  section  of  the  skull.  Therefore  in 
those  cases  in  which  the  pressure  symptoms  are 
very  marked  but  the  tumor  cannot  be  localized  he 
recommends  the  removal  of  the  cerebrospinal  fluid 
by  Quincke's  lumbar  puncture.  This  procedure 
he  says  is  much  to  be  preferred  to  any  others,  but 
failing  in  this  recourse  should  be  had  to  direct 
puncture  of  the  lateral  ventricles.  According  to 
Oppenheim  lumbar  puncture  is  indicated  in  a  very 
limited  number  of  cases,  chief  among  which  are 
those  in  which  the  tumor  is  associated  with  an 
internal  hydrocephalus  and  especially  when  the 
tumor  encroaches  upon  the  posterior  fossa  and 
threatens  the  life  of  the  patient.  In  a  series  of  50 
cases  collected  by  Piollet  (Archives  provinciales  de 
chirurgie,  Vol.  x,  p.  728)  lumbar  puncture  was 
employed  in  eight  cases ;  in  four  patients  there  was 
transitory  amelioration,  and  four  died  within  a  few 
days.  The  sudden  disturbance  of  pressure  is  no  doubt 
responsible  for  a  large  majority  of  the  fatalities. 
In  a  few  cases  the  fatal  issue  has  been  attributed  to 
the  pressure  of  the  structure  of  the  posterior  fossa 
against  the  foramen  magnum,  an  accident  which 
could  easily  happen  when  the  communication  be- 
tween the  cerebral  and  spinal  cavities  was  partly 
or  altogether  shut  off  and  the  vacuum  created  by 
aspiration  drew  the  pons  and  medulla  forcibly  into 


56 

the  foramen  magnum.  If  lumbar  puncture  is  re- 
sorted to,  such  an  apparatus  should  be  used  as 
Koenig  suggested,  in  which  the  pressure  is  recorded 
while  the  fluid  is  being  withdrawn.  With  this 
precautionary  measure  the  danger  of  lumbar  punc- 
ture would  be  reduced  to  a  minimum.  Fiirbinger 
who  is  very  much  opposed  to  this  practice  attributes 
the  deaths  to  pressure  exerted  upon  the  bulb  by  the 
arrest  of  cerebrospinal  fluid  from  the  ventricles  at 
the  foramen  of  Magendie. 

CONTINUOUS    OR    INTERMEDIATE    DISCHARGE    OF 
CEREBROSPINAL   FLUID. 

The  advisability  of  affording  means  for  the  es- 
cape of  cerebrospinal  fluid  as  a  palliative  measure 
might  well  be  considered  in  connection  with  punc- 
ture of  the  lateral  ventricle  or  lumbar  puncture. 
There  are  cases  on  record  in  which,  subsequent  to 
operation,  the  flap  has  been  punctured  repeatedly 
for  the  purpose  of  relieving  tension.  After  an  ex- 
ploratory operation,  in  which  the  tumor  was  not 
found,Terrier  punctured  the  flap  repeatedly  and 
withdrew  a  considerable  quantity  of  fluid,  but  the 
patient  died  in  the  third  week  after  this  form  of 
treatment  was  adopted.  Jaboulay  noticed  the  bene- 
ficial effect  attending  the  escape  of  cerebrospinal 
fluid  through  a  fistula  in  the  cicatrix  and  recom- 
mends the  establishment  of  such  a  fistula  in  cases 


57 

in  which  the  improvement  after  operation  was  only 
transitory  or  in  which  there  was  no  improvement. 
Theoretically  at  least  such  a  treatment  should  af- 
ford some  relief  from  the  effects  of  intracranial 
pressure  and  might  be  justifiable  in  inoperable  cases, 
but  one  must  bear  in  mind  the  constant  danger  of 
infection  that  must  needs  attend  the  presence  of  a 
communicative  tract  between  the  surface  and  the 
underlying  structures. 

EXPOSURE  OF  THE   CEREBELLOPONTILE   ANGLE. 

To  return  to  the  question  of  exploration  from 
which  we  digressed  to  consider  the  propriety  of 
puncture  of  the  lateral  ventricles :  To  enable  one 
to  expose  a  tumor  situated  in  the  cerebellopontile 
angle  two  methods  were  proposed,  tapping  of  the 
lateral  ventricles,  and  removal  of  a  large  portion 
of  the  cerebellar  hemisphere.  The  former  method 
we  disapprove  of  on  the  grounds  that  it  is  so  fatal 
in  its  tendencies.  The  alternative  on  the  other  hand 
is  attended  with  very  different  results.  The  im- 
punity with  which  large  sections  of  cerebellar  tissue 
may  be  cut  away  not  only  without  endangering  life 
but  without  disturbance  of  function  is  an  observa- 
tion which  was  made  by  physiologists  long  ago. 
That  the  deduction  naturally  to  be  drawn  from  this 
bit  of  laboratory  information  has  not  been  made  use 
of  by  surgeons  more  generally  is  a  matter  of  some 


58 

surprise.  The  danger  of  exerting  undue  pressure 
or  traction  upon  the  pons  or  medulla  in  attempting 
to  expose  or  remove  the  tumor  is  more  to  be  dreaded 
than  any  other  stage  of  the  operation.  It  was  only 
recently  that  Woolsey  (Annals  of  Surgery,  Septem- 
ber, 1904)  reported  a  case  of  neurofibroma  of  the 
acoustic  nerve ;  the  tumor  was  removed  but  the  pa- 
tient died  three  hours  after  the  operation,  and  death 
was  believed  to  be  due  to  haemorrhage  within  the 
pons.  Woolsey  was  convinced  that  this  was  due 
to  the  traumatism  indispensable  to  the  frequent  in- 
troduction and  withdrawal  of  the  fingers  engaged  in 
the  removal  of  the  tumor.  Here  is  a  case  in  which 
had  a  considerable  portion  of  the  hemisphere  been 
removed  prior  to  the  attempts  to  extract  the  tumor 
it  is  more  than  likely  that  the  unfortunate  accident 
would  not  have  occurred.  My  experience  with  this 
procedure  has  been  limited  to  two  cases  which  will 
be  referred  to  again.  In  one  of  these  (Case  2)  a 
considerable  portion — from  one  third  to  one  half — 
of  the  hemisphere  was  removed  deliberately  in 
searching  for  the  tumor,  without  any  appreciable 
effect  upon  the  patient's  general  condition.  In  an- 
other case  (Case  4)  the  same  practice  was  adopted 
with  equally  negative  results  in  so  far  as  the  pa- 
tient's respiratory  or  circulatory  functions  were  con- 
cerned. In  neither  of  these  cases  was  the  tumor 
found  at  the  first  operation,  but  the  amelioration 


59 

that  followed  was  striking.  At  a  second  operation 
upon  one  of  these  (Case  2)  the  tumor  presented 
itself  upon  the  surface  of  the  remainder  of  the  cere- 
bellar tissue  and  was  removed  without  any  difficulty. 
This  experience  at  once  suggested  to  my  mind  what 
would  seem  to  be  additional  argument  in  favor  of 
the  deliberate  removal  of  a  large  portion  of  the 
hemisphere;  on  the  one  hand  serving  as  a  means 
of  affording  adequate  exposure  with  the  minimum 
degree  of  traumatism  to  pons  and  medulla,  on  the 
other  serving  as  a  means  of  relieving  intracranial 
tension  temporarily,  and  at  the  same  time,  by  re- 
moving a  certain  amount  of  resistance,  of  facilitat- 
ing the  growth  of  the  tumor  toward  the  surface  of  a 
point  where  it  can  be  more  easily  seen  and  removed. 
Last  year  Hudson  (American  Journal  of  the  Medi- 
cal Sciences,  September,  1903)  reported  two  opera- 
tions for  cerebellar  tumors,  in  one  of  which  at  least 
a  large  portion  of  the  hemisphere  was  removed  in 
searching  for  the  tumor.  The  patient  reacted 
promptly  and  although  the  tumor  was  not  found, 
began  at  once  to  improve.  On  a  subsequent  occa- 
sion the  wound  was  reopened  and  a  large  cyst  found 
and  evacuated.  I  feel  convinced  that  this  procedure, 
if  more  universally  adopted,  will  do  much  toward 
increasing  the  percentage  not  only  of  tumors  found, 
but  of  tumors  removed,  and  will  at  the  same  time 
reduce  the  mortality. 


60 


SHORTEST  ROUTE  TO  THE  CEREBELLOPONTILE   ANGLE. 

Before  concluding  our  remarks  upon  the  means 
of  exposing  tumors  in  the  cerebellopontile  angle  a 
word  should  be  said  concerning  the  best  method  of 
approach.  One  has  but  to  turn  to  a  cross  section 
of  the  cerebellum  to  see  that  the  shortest  distance 
from  the  surface  of  the  skull  to  this  snug  corner  is 
along  a  line  parallel  with  the  petrous  portion  of  the 
temporal  bone  (see  Fig.  3).  Krause,  in  describ- 
ing an  operation  for  the  division  of  the  eighth  nerve 
{Beitrdge  zur  klinische  chirurgie,  Bd.  XXXVII, 
Heft.  3),  and  others  have  made  this  anatomical  ob- 
servation. The  distance  along  this  line  being  the 
shortest  it  goes  without  saying  that  the  cerebello- 
pontile angle  should  be  approached  from  the  lateral 
rather  than  superior  or  inferior  aspects  of  the  cere- 
bellum. The  bony  opening  should  extend  as  near  to 
the  mastoid  process  as  possible.  This  is  not  only 
the  shortest  but  the  safest  route  in  that  the  manipu- 
lations are  carried  on  at  a  point  farthest  distant 
from  such  vital  structures  as  the  pons  and  medulla. 

OPERATIONS    UPON   THE   FIFTH   AND   EIGHTH    NERVES 
IN   THE   CEREBELLAR   FOSSA. 

In  an  exploration  of  the  anterior  aspects  of  the 
cerebellum  in  the  cerebellopontile  angle  for  tumors, 
one  exposes  the  posterior  plane  of  the  petrous  por- 
tion of  the  temporal  bone,  and  with  it  the  fifth, 


Fig.  3.— Photograph  of  a  horizontal  section  of  the  head  cut  on  a  level 
with  the  external  auditory  meatus  ;  a,  representing  a  point  at  the 
cerebellopontile  angle  ;  b,  the  auditory  nerve  entering  the  internal 
auditory  meatus  ;  c,  d,  e,  three  points  on  the  skull.  Note  the  dis- 
tance between  point  a,  and  the  points  c,  d,  and  e  as  illustrating  the 
shortest  route  to  the  cerebellopontile  angle  respectively.  The 
shortest  distance  from  the  skull  to  the  angle  is  measured  along  a 
line  drawn  between  a  and  c.  The  farther  away  from  c  or  the 
nearer  to  e  the  greater  will  be  this  distance. 


63 

seventh,  and  eighth  nerves  (see  Fig.  4).  The 
seventh  and  eighth  nerves  will  be  seen  passing  from 
the  cerebellum  to  enter  the  internal  auditory  meatus. 
The  eighth  nerve  is  the  larger  of  the  two  and  over- 
lies the  seventh  nerve  in  such  a  way  that  it  almost 
entirely  conceals  it  from  view.  Farther  along,  at 
the  apex  of  the  petrous  portion  of  the  temporal 
bone,  will  be  seen  the  sensory  root  of  the  trigeminus 
as  it  passes  into  the  groove  in  which  it  traverses 
the  petrous  bone  to  enter  the  Gasserian  ganglion. 
These  three  nerves,  together  with  the  ninth,  tenth, 
and  eleventh,  may  be  said  to  be  accessible,  so  that 
it  is  quite  possible,  if  the  indications  arise,  to  divide 
any  of  them.  It  is  not  likely  that,  in  operations  for 
the  relief  of  trifacial  neuralgia,  one  would  be  called 
upon  to  divide  the  sensory  root  in  the  cerebellar 
fossa  because  the  root  and  ganglion  are  more  easily 
approached  by  the  temporal  route.  In  one  of  the 
cases  of  our  series  we  seriously  discussed  the  possi- 
bility of  dividing  the  root  in  the  cerebellar  fossa 
and  fully  intended  to  do  so  under  certain  conditions. 
The  case  was  one  in  which  there  were  certain  symp- 
toms of  cerebellar  tumor  and  in  addition  intense 
trifacial  neuralgia.  If  the  tumor  could  not  be  found 
it  was  thought  best  to  afford  the  patient  relief  at 
least  from  the  neuralgia  by  dividing  the  sensory- 
root.  However,  a  cyst  was  found  and  evacuated 
and  no  further  intervention  seemed  advisable.    The 


64 


patient  was  relieved  entirely  and  has  remained  free 
from  pain  now  more  than  a  year  since  operation. 
There  is  no  conceivable  indication  for  any  opera- 
tive attack  upon  the  seventh  nerve  within  the  fossa, 
but  in  the  case  of  the  eighth  nerve  Krause  has 
recommended  and  practised  its  division  for  the  re- 
lief of  persistent  tinnitus  aurium.  As  recommended 
for  tumors  of  the  cerebellopontile  angle,  so  here 
the  nerve  should  be  approached  from  the  lateral 
rather  than  posterior  aspect  as  from  this  point  is 
measured  the  shortest  distance  from  the  skull  to  the 
nerve.  The  only  difficulty,  if  there  is  any  in  the 
operation,  will  be  met  with  in  separating  the  eighth 
from  the  seventh  nerve.  The  latter  as  has  been  said 
lies  directly  behind  as  one  views  the  field  from  the 
side  and  the  precaution  must  be  taken  to  separate 
one  from  the  other  before  attempting  a  nerve  sec- 
tion. This  is  readily  done  with  the  aid  of  a  small 
blunt  hook  (see  Fig.  4). 

SIMULTANEOUS    EXPOSURE    OF    BOTH    HEMISPHERES; 
BILATERAL    CRANIECTOMY. 

The  difficulty  in  localizing  cerebellar  tumors  is 
known  to  all  cHnicians.  In  an  analysis  of  the  116 
cases  which  we  have  collected  we  find  that  in  55  per 
cent,  the  operation  was  a  failure  because  the  tumor 
was  not  found.  The  diagnosis  of  cerebellar  tumor  is 
in  many  cases  not  so  difficult,  but  in  many  of  these 


Fig.  4. — The  larger  figure  to  the  left  illustrates  the  operation 
for  the  combined  exposure  of  one  cerebellar  hemisphere  and 
the    occipital    lobe   of   the    cerebrum.      The   smaller   figure, 


above  and  to  the  right,  illustrates  the  structures  in  relation 
to  the  anterior  aspect  of  the  cerebellum  and  the  petrous 
portion  of  the  temporal  bone.  Attention  is  called  especially 
to  the  position  of  the  5th,  7th,  and  8th  cranial  nerves. 
This  drawing  was  made  by  viewing  the  structures  from  the 
lateral  aspect,  such  an  exposure  as  would  be  made  In  ex- 
ploring for  tumors  of  the  cerebellopontile  angle.  1.  Osteo- 
plastic flap  reflected  in  an  operation  for  the  combined  ex- 
posure of  occipital  lobe  and  cerebellum.  2.  Ninth,  tenth, 
and  eleventh  cranial  nerves.  3.  Auditory  nerve  drawn  to 
one  side  by  refractor  in  order  to  expose.  4.  The  facial 
nerve  which  lies  directly  beneath  it.  5.  The  root  of  the 
trigeminus  as  it  enters  the  groove  at  the  apex  of  the 
petrous  portion  of  the  temporal  bone. 


Fig.  5. — Operation  for  the  simultaneous  exposure  of  both  cere- 
bellar hemispheres,  necessitating  ligation  of  the  occipital 
sinus.  1.  The  occipital  sinus,  which  has  been  ligated  previ- 
ously and  reflected  with  the  dura.  2.  Mastoid  process.  3.  A 
large  tributary  of  the  lateral  sinus,  invariably  opened  In 
cerebellar  craniectomies  and  of  varying  dimensions ;  said  to 
be  sometimes  as  large  as  the  lateral  sinus.  4.  Lateral  sinus. 
5.  Occipital  protuberance.     6.  Occipital  sinus. 


69 

it  will  be  almost  impossible  to  determine  beforehand 
whether  the  tumor  is  in  the  right  or  left  lobe. 
Therefore  in  the  course  of  an  exploratory  opera- 
tion, when  one  has  failed  after  a  thorough  search 
to  find  the  tumor  on  the  side  which  was  opened  first 
one  must  decide  whether  to  proceed  at  once  to  ex- 
plore the  opposite  side.  In  most  instances  further 
exploration  should  be  postponed  until  the  patient 
has  reacted  from  the  effects  of  the  injury  already 
inflicted.  In  one  of  our  cases  already  referred  to 
(Case  4)  a  section  of  the  cerebellar  hemisphere  was 
removed  to  relieve  tension  temporarily  and  with 
most  gratifying  results.  But  whether  this  pro- 
cedure is  justifiable  in  the  light  of  the  probable  ex- 
istence of  a  tumor  on  the  other  side,  might  with 
propriety  be  questioned.  In  order  to  enable  one  to 
examine  both  hemispheres  at  one  sitting  the  authors 
discussed  the  feasibility  of  performing  a  craniec- 
tomy on  both  sides  and  removing  the  intervening 
bone.  This  operation  was  performed  upon  the 
cadaver  from  which  the  illustration  in  Fig.  5 
was  drawn.  The  operation  may  be  carried  out  as 
follows:  An  opening  is  made  on  either  side  in  a 
manner  similar  to  that  when  the  operator  is  con- 
fined to  one  side.  The  dura  and  with  it  the  superior 
longitudinal  sinus  are  separated  so  that  they  may 
escape  injury  when  the  overlying  bone  is  divided; 
a  pair  of  forceps  or  preferably  a  Gigli  saw  may  be 


70 

used  to  section  the  intervening  bridge  of  bone.  The 
Gigli  saw  is  to  be  preferred  because  it  is  less  likely 
to  comminute  the  bone,  which  must  be  divided  very 
near  the  foramen  magnum.  The  falx  cerebelli  is 
punctured  in  either  side  of  the  occipital  sinus  and 
the  sinus  divided  between  two  ligatures  (see  Fig. 
5).  This  will  enable  one  to  reflect  a  flap  of  the 
dura  covering  both  hemispheres  and  afterwards 
to  displace  the  cerebellum  with  greater  freedom 
than  would  be  possible  if  an  unyielding  bridge  of 
bone  remained  between  the  two  openings.  In  the 
preparation  of  this  paper  we  found  upon  perusal 
of  the  literature  that  this  procedure  has  been  recom- 
mended by  Kocher,  Nothnagel  (Path.  u.  Ther.,  Vol. 
IX),  and  Krause  {Beitrdge  zur  klin.  Chir.,  Bd. 
XXXVII).  The  latter  performed  this  operation  in 
a  case  in  which  there  was  much  uncertainty  as  to 
the  position  of  the  tumor ;  in  order  to  relieve  tension 
still  further,  he  punctured  one  lateral  ventricle.  The 
results  were  reported  to  be  satisfactory  in  so  far 
as  the  freedom  with  which  the  various  aspects  of 
the  cerebellum  could  be  exposed.  The  patient  died 
one  week  later  and  the  autopsy  revealed  an  internal 
hydrocephalus,  but  no  tumor.  We  are  not  prepared 
to  endorse  this  operation  as  a  routine  procedure 
but  believe  it  should  be  restricted  to  those  cases  in 
which  the  tumor  is  believed  to  occupy  a  position 
near  the  mesial  surface.     Under  any  circumstances 


71 


it  should  be  practiced  at  two  sittings ;  the  additional 
trauma  and  haemorrhage  which  must  accompany 
such  an  extensive  incision  and  the  removal  of  such 
an  extensive  section  of  bone  would  we  believe  add 
materially  to  the  gravity  of  what  under  any  cir- 
cumstances is  an  extraordinarily  serious  opera- 
tion. 

LIGATURE  OF  THE  LATERAL  SINUS. 

A  discussion  of  the  operative  procedures  in  the 
region  of  the  cerebellum  would  be  incomplete  did 
we  not  include  some  reference  to  ligation  of  the 
lateral  sinus.  In  an  attempt  to  expose  tumors  par- 
ticularly of  the  anterior  surface  of  the  cerebellum 
the  operator  is  hampered  by  the  tentorium  cerebelli, 
and  the  suggestion  has  been  made  by  Kocher, 
Krause,  and  others  that  the  tentorium  cerebelli  be 
divided  down  to  the  petrous  portion  of  the  tem- 
poral bone  after  the  lateral  sinus  has  been  ligated. 
It  is  stated  by  Krause  that  one  of  the  sinuses  can 
be  ligated  without  much  risk,  and  on  at  least  one 
occasion  the  idea  was  put  into  effect.  The  advan- 
tage to  be  gained  by  this  modification  of  the  tech- 
nique I  do  not  believe  compensates  for  the  additional 
risk  that  must  be  entailed.  If  the  mortality  follow- 
ing operations  upon  the  cerebellum  is  to  be  reduced, 
the  technique  must  be  as  simple  as  possible,  the  least 


72 

degree  of  traumatism  must  be  inflicted,  the  smallest 
possible  insult  ojffered  to  the  tissues;  therefore  we 
should  discard  the  more  complicated  procedures 
and  those  which  interfere  to  a  greater  degree  with 
the  circulation  and  functional  activity  of  the  struc- 
tures concerned. 

SIMULTANEOUS    EXPOSURE    OF    THE    OCCIPITAL    LOBE 
AND    CEREBELLAR    HEMISPHERE. 

Included  on  the  list  of  doubtful  diagnoses  are 
those  in  which  there  is  a  reasonable  doubt  as  to 
whether  the  tumor  is  situated  in  the  cerebellum  or 
the  occipital  lobe.  In  such  cases  one  could  at  one 
sitting  explore  first  the  cerebellum  by  a  craniectomy 
and  the  occipital  lobe  by  a  craniotomy  (see  Fig. 
4). 

RESULTS. 

To  speak  first  of  the  results  of  the  cases  which 
have  come  under  the  author's  observation:  During 
the  past  twelve  months,  six  patients  have  been  sub- 
jected to  operation  at  the  University  Hospital :  five 
of  them  were  patients  of  Dr.  Mills,  and  one  was  a 
patient  of  Dr.  McCarthy.  The  records  of  these 
cases  appear  below,  but  the  results  may  be  expressed 
briefly  in  the  following  table : 


73 


-CASES    UNDBE   AUTHOR'S   OBSERVATION   DUBING   PAST 
TWELVE   MONTHS. 


Case  1 . 


Case  2. . 


Case  3. 


Case  4 . 


Case  5. . 


Case  6. . 


Craniectomy. 


Craniectomy. 


Unilateral    cra- 
niectomy. 


Craniectomy. 


Craniectomy ;  2 
stage  operatioT 
planned. 


Craniectomy . 


Tumor  found 
and  removed. 


Tumor  found 
and  removed. 


Tumor  not 
found . 


Tumor  not 
found ;  one- 
third     of 
hemisphere 
removed 

Dura     not 
opened. 


Cyst  found 
and  evacu- 
ated. 


Recovery. 


Recovery.* 


Recovery  from  opera- 
tion, without  im- 
provement. Patient 
would  not  consent  to 
further    exploration. 

Striking  improvement. 
Restoration  of  vi- 
sion, relieved  of 
headache,  vomiting, 
and  vertigo. 

Death,  sudden  and  un- 
accountable, twelve 
hours      after      first 


Recovery  from  opera- 
tion ;  great  relief  of 
headache  and  other 
symptoms. 


*  Since  this  writing  there  has  been  a  recurrence  of  the  growth. 

Still  further  condensed  the  results  were  as  fol- 
lows :  Of  6  cases :  i  died  after  first  stage  of  opera- 
tion ;  2  recovered  after  removal  of  tumor ;  i  relieved 
after  evacuation  of  cyst,  no  recurrence  more  than 
a  year  after  operation;  i  considerably  improved 
after  palliative  operation ;  i  no  improvement ;  tumor 
not  found. 

My  personal  experience  with  this  series  of  cases 
leads  me  to  believe  that  the  dangers  attending  cere- 
bellar operations  have  been  somewhat  exaggerated. 


74 

The  present  generation  of  surgeons  has  inherited 
the  traditional  fear  of  operations  within  the  cranial 
cavity.  It  was  not  very  long  ago  that  operations  upon 
the  Gasserian  ganglion  were  regarded  as  desperate 
undertakings,  when  it  was  a  case  of  kill  or  cure, 
whereas  at  the  present  time  the  operation  is  under- 
taken with  no  especial  concern  except  upon  individ- 
uals, who  on  account  of  their  advanced  years  might 
be  unfavorable  subjects  for  any  major  operation. 
And  so  it  is  with  tumors  of  the  brain  generally  and 
especially  with  regard  to  tumors  of  the  cerebellum. 
Physicians  put  off  the  question  of  operation  until 
the  patient's  condition  becomes  critical  and  the 
surgeon  undertakes  the  operation  with  fear  and 
reluctance.  It  was  not  so  long  ago  that  Oppenheim 
classed  all  tumors  of  the  cerebellum  as  inoperable, 
but  in  the  last  editions  of  his  book  (1902)  he  frank- 
ly confesses  that  his  opinion  on  this  point  is  in  need 
of  revision. 

The  dangers  and  risk  peculiar  to  this  operation 
lie  in  the  proximity  of  the  medulla  and  pons  to  the 
field  of  operation  and  the  traumatism  to  which  they 
may  be  subjected  in  the  course  of  the  operation.  It 
is  on  this  account  that  stress  has  been  laid  upon 
the  advisability  of  approaching  the  cerebellopontile 
angle  from  the  lateral  aspect  in  order  not  to  injure 
these  structures.  In  a  case  of  Woolsey's  previously 
referred  to,  the  autopsy  revealed  a  haemorrhage  in 


75 

the  pons  which  the  operator  attributed  to  the  trau- 
matism to  which  it  was  subjected  while  he  was  re- 
moving piecemeal  a  tumor  of  the  auditory  nerve. 
If  in  the  fatal  cases  a  careful  examination  of  pons 
and  medulla  had  been  made  we  believe  that  in  a 
majority  some  evidence  of  traumatism  would  have 
been  found.  It  is  only  in  the  avoidance  of  every 
possible  source  or  degree  of  traumatism  to  these 
vital  structures  that  surgeons  can  hope  to  obtain 
better  results.  In  this  connection  we  refer  again 
to  the  impunity  with  which  a  considerable  portion 
of  one  cerebellar  hemisphere  can  be  removed,  since 
by  so  doing  the  operator  not  only  can  explore  and 
expose  the  tumor,  but  also  remove  it  without  the 
necessity  of  exerting  undue  traction  or  pressure 
directly  or  indirectly  upon  the  pons.  This  of  course 
applies  especially  to  tumors  that  were  not  within 
the  hemisphere. 

We  have  been  struck  especially  with  the  com- 
paratively slight  depression  attending  operations 
upon  the  cerebellum  and  with  the  rapidity  with 
which  reaction  ensues.  In  one  of  our  cases  the  pa- 
tient lost  a  large  quantity  of  blood  in  a  very  short 
time,  but  recovered  promptly  from  the  effects,  after 
the  administration  of  appropriate  remedies.  This 
patient  died  twelve  hours  after  the  operation  sud- 
denly and  unexpectedly,  but  ten  minutes  before  he 
died  his  general  condition  was  reported  as  excellent. 


76 

Our  experiences,  however,  we  believe  to  be  excep- 
tional, as  there  are  recorded  in  literature  many  cases 
in  which  the  patients  died  on  the  table  or  a  few  hours 
after  the  operation. 

We  have  noted,  however,  that  the  gravity  of  the 
operation  does  not  seem  to  have  been  affected  by 
the  act  of  removing  the  tumor;  whether  the  opera- 
tion was  solely  exploratory  or  palliative,  or  whether 
a  tumor  was  removed,  the  effect  upon  the  patient 
was  the  same. 

In  all  these  operations  careful  records,  of  the 
blood  pressure  were  made,  with  a  view  of  ascer- 
taining whether  the  actual  removal  of  the  tumor 
was  attended  with  or  followed  by  lowering  of  the 
blood  pressure.  The  results,  however,  were  nega- 
tive. 

STATISTICAL    STUDY     OF     Il6     CASES     OF     OPERATION 
UPON  THE  CEREBELLUM,  COLLECTED  BY  FRAZIER. 

The  following  statistics  were  compiled  from  the 
ii6  cases  of  cerebellar  tumors  found  in  the  ap- 
pended table,  pp.  334  to  337: 

Per  cent. 

Tumors   found 45 

Tumors  not  found 55 

Removal  with  recovery 15 

Removal  with  improvement 13.9 

Removal  without  improvement 0.9 

Improvement  without  removal 13.9 

No  improvement  without  removal 13.9 

Death  when  tumor  was  removed 12.9 

Death  when  tumor  was  not  found  and  not  removed 28.7 


77 


A  COMPABISON  OF  THE  STATISTICS  OP  SUCCESSIVE  DATES,  SHOW- 
ING AN  INCKBASE  IN  THE  PEECENTAGB  OF  EECOVBEIES  AND 
IMPEOVEMENTS,  AND   A    EEDUCTION    IN   THE    MOETALITY. 

Frazier's  Buret's  Oppenheim'a 

table.— 1904.  table.— 1903.  table.— 1902. 

Results.                              Per  cent.  Per  cent.  Per  cent. 

Recovery   15  14  7.5 

Improved 28  25  7.5 

Unimproved   15  . .  13 

Mortality    42  60  71 

A  COMPAEISON  OF  THE  STATISTICS  OF  TOTAL  NUMBBE  OF  CASflS 
IN  FEAZIEE'S  COLLECTION  WITH  THE  STATISTICS  OF  THE 
LAST  FIVE  YEAESj  SHOWING  A  MANIFEST  IMPEOVEMENT  IN 
THE  EBSOLTS. 

Cases 
reported  during 
Total  number       past  five  years, 
of  cases.  1899—1904. 

Results.  Per  cent.  Per  cent. 

Recovery    15  24 

Improved 28  28.5 

Unimproved   15  11 

Mortality    42  35.8 

From  a  review  of  these  tables  one  is  struck  at 
once  with  the  progress  that  has  been  made  in  this 
field  of  surgery  from  every  point  of  view.  The  per- 
centage of  tumors  found  is  yearly  growing  larger, 
the  percentage  of  partial  or  complete  recoveries  is 
larger  and  the  mortality  has  fallen  from  70  per  cent, 
to  38  per  cent.  We  believe  that  the  results  of  sur- 
gical intervention  upon  the  cerebellar  hemisphere 
will  continue  to  improve,  if  not  generally,  at  least  in 
the  hands  of  those  who  are  giving  this  subject  es- 
pecial thought  and  attention. 


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CASKS    II.I.USTRATING    PAPERS    OF    DR. 
MILIvS  AND  DR.  FRAZIBR. 

Case  I. — Tumor  of  the  left  lateral  lobe  of  the 
cerebellum  ;  operation  ;  recovery. 

L.  P.,  white,  single,  aged  twenty-three  years, 
was  admitted  to  the  Hospital  of  the  University  of 
Pennsylvania  December  7,  1903.  Her  family  his- 
tory was  negative.  She  was  strong  and  well  un- 
til the  beginning  of  the  illness,  which  brought  her 
to  the  hospital. 

In  February,  1903,  she  began  to  have  severe 
headaches  with  attacks  characterized  by  vertigo, 
especially  when  standing  and  walking,  but  occa- 
sionally when  lying  down.  She  also  at  times 
early  in  the  attack  had  a  series  of  visual  and  ocu- 
lar phenomena,  including  temporary  hemianop- 
sia ;  scotoma  either  early  or  late ;  light  flashes 
sometimes  lasting  throughout  an  attack ;  sub- 
jective images,  especially  about  the  time  of  her 
coming  to  the  hospital,  when  she  saw  dogs,  cats, 
mice,  bugs,  spiders,  etc. ;  and  diplopia  in  which 
one  image  would  be  in  advance  of  the  other,  this 
being  especially  constant  in  the  left  eye.  Nausea 
preceded,  accompanied,  or  came  on  late  in  the 
attack.  Vomiting  generally  appeared  late  in  the 
attack  and  gave  the  patient  some  relief. 

Her  headache  was  located  in  the  forehead  or 
at  the  base,  or  more  commonly  in  both  regions  at 
the  same  time.  From  February,  1903,  to  Septem- 
ber, 1903,  the  patient  had  suffered  from  these  at- 
tacks once  every  five  days,  with  the  exception  of 


87 


two  weeks  in  July.  About  the  middle  of  August, 
1903,  and  in  October,  1903,  her  gait  became  stag- 
gering. During  the  latter  part  of  November  up 
to  the  time  of  admission  to  the  hospital  she  had 
been  unable  to  walk  more  than  a  few  steps  with- 
out support.  Since  August,  1903,  the  headaches 
had  been  more  or  less  constant.  On  admission 
to  the  hospital  she  complained  especially  of  nau- 
sea and  of  severe  frontal  headache,  of  pain  in  the 
back  of  her  head  and  neck,  and  in  her  back.  This 
patient  was  admitted  to  the  University  Hospital 
under  the  care  of  Dr.  J.  D.  Steele,  and  was  later 
transferred  to  the  service  of  Dr.  Mills.  Careful 
examinations  were  made  by  Dr.  Steele,  but  with 
negative  results,  except  as  regards  her  nervous 
system,  and  the  existence  of  patches  of  brown 
pigmentation  over  the  entire  body.  Examina- 
tions of  both  urine  and  blood  were  negative. 

Later  repeated  examinations  were  made  by  Dr. 
Mills  and  also  by  Dr.  Spiller  in  consultation.  The 
results  of  these  examinations  can  be  summarized, 
as  but  little  change  took  place  until  the  time  of 
operation,  except  for  the  worse  as  regards  par- 
ticular symptoms,  like  optic  neuritis,  headache, 
nausea,  and  ataxia.  The  patient  exhibited  marked 
ataxia  of  station.  The  incoordination  in  stand- 
ing was  usually  not  increased  by  closing  the  eyes. 
Numerous  examinations  showed  a  tendency  of 
the  patient  to  deviate,  pitch,  or  fall  to  the  left  in 
standing  and  walking;  exceptionally  the  tend- 
ency was  in  the  other  direction.  Testing  the  ex- 
tremities separately,  fairly  marked  ataxia  was 
present  on  the  left,  and  to  a  slighter  extent  on 


the  right.  On  several  examinations  the  patient 
showed  distinct  asynergia  in  the  left  lower  ex- 
tremity. The  symptom  was  not,  however,  uni- 
formly present,  and  on  at  least  one  occasion  some 
asynergia  seemed  to  be  present  in  the  right.  The 
Babinski  response  was  present  on  the  right ;  both 
knee  jerks  were  absent  and  the  tendon  and  mus- 
cle jerks  in  the  upper  and  lower  extremities  were 
generally  depressed.  Apparently  the  movements 
of  both  external  straight  muscles  were  at  times 
impaired,  although  the  report  of  Dr.  de  Schwein- 
itz  showed  abducens  weakness  only  on  the  left. 
On  the  negative  side  nystagmus  was  absent,  as 
were  also  involvement  of  the  fifth,  seventh,  or 
other  cranial  nerves,  and  of  disturbances  of  sen- 
sation. The  patient  continued  to  suffer  greatly 
from  headache,  vertigo,  nausea,  and  vomiting,  the 
optic  neuritis  increasing  and  becoming  of  the 
highest  grade. 

Eye  examinations  were  made  by  Dr.  G.  E.  de 
Schweinitz,  who  reported  as  follows :  December 
8,  1903,  the  vision  of  each  eye  equals  hand  move- 
ments. The  pupils  react  sluggishly  to  light  and 
convergence.  There  is  a  history  of  diplopia  and 
there  probably  is  paresis  of  the  left  external  rec- 
tus, but  the  double  images  cannot  be  elicited,  and 
this  is  inferred  only  from  the  failure  of  rotation 
in  the  line  of  the  direction  of  the  action  of  the 
left  externus.  The  ophthalmoscope  reveals  the 
following  conditions :  in  the  right  eye  there  is  a 
high  grade  of  papillitis  (choked  disc),  the  apex 
of  the  swelling  being  7  D.  It  is  intensely  in- 
jected, and  the  sloping  margins  of  the  elevation 


89 

are  thickly  infiltrated  with  haemorrhages.  In  the 
left  eye  there  is  an  exactly  similar  condition,  and 
in  addition  a  typical  macular  figure  resembling 
that  seen  in  albuminuric  retinitis.  Careful  test- 
ing of  the  visual  field  indicates  that  while  it  is 
contracted  there  is  no  hemianopic  defect. 

December  ly,  1903,  Dr.  Frazier  operated.  An 
incision  was  made,  following  and  a  little  above 
the  superior  curved  line  from  the  mastoid  proc- 
ess to  the  occipital  protuberance,  and  thence 
downwards  in  the  median  line  for  a  distance  of  4 
cm.  The  opening  in  the  skull  was  made  with  the 
chisel  and  enlarged  with  the  rongeur  forceps. 
The  dura  was  normal  in  appearance  and  seemed 
thinner  than  usual,  and  seemed  unusually  tense, 
A  dural  flap  was  reflected  and  the  surface  of  the 
hemisphere  inspected.  Failing  to  determine  the 
presence  of  a  tumor  by  the  sense  of  sight  or  touch, 
an  incision  was  made  in  the  left  cerebellar  hemi- 
sphere, which  revealed  a  small  encapsulated  tu- 
mor of  about  the  size  of  a  hazelnut ;  the  tumor 
was  easily  shelled  out.  The  protrusion  of  the 
cerebellar  tissue  was  so  great  that  it  was  neces- 
sary to  remove,  in  addition,  about  one  fourth 
of  the  cerebellar  hemisphere  in  order  to  be  able 
to  close  the  dural  wound.  The  patient  reacted 
promptly  from  the  operation,  and  convalescence 
was  uninterrupted. 

The  following  reports  were  made  by  Dr,  de 
Schweinitz  after  the  operation : 

December  20,  1903. — The  changes  evident  to 
the  ophthalmoscope  are  almost  exactly  those 
which  have  been  recorded,  with  the  exception  of 


90 


some  fresh  haemorrhages  which  have  appeared  on 
the  nasal  halves  of  the  swollen  nerve  heads. 

January  4,  1904. — The  ophthalmoscopic  ap- 
pearances noted  by  Dr.  Shumway  are  double  op- 
tic neuritis,  plus  6  D.  The  vision  of  the  right  eye 
is  doubtful  light  perception.  The  left  eye  is  ab- 
solutely blind.  A  repetition  of  his  examination 
on  the  following  day  by  Dr.  de  Schweinitz  con- 
firmed the  observations.  No  changes  were  noted 
at  the  next  examination,  on  the  7th  of  January. 

Examination,  January  17,  1904. — There  is 
marked  subsidence  of  the  swelling  of  the  discs, 
the  apices  of  which  are  not  more  than  3  D.,  and 
the  edges  of  the  disc  margins  are  beginning  to 
appear.  The  macular  figure  noted  before  is  very 
marked,  and  is  now  evident  in  both  eyes.  The 
retinal  vessels  are  beginning  to  shrink  and  atro- 
phy is  rapidly  supervening.  There  is  no  light 
perception.  This  examination  was  repeated  on 
January  25th,  with  practically  the  same  results, 
possibly  still  further  diminution  of  the  swelling 
of  the  discs.  Some  weeks  later,  after  the  patient 
was  dismissed  from  the  hospital,  the  ordinary 
signs  of  postneuritic  atrophy  were  present.  The 
eyes  were  divergent,  the  pupils  large  and  not  re- 
sponding to  light. 

This  patient  who  presented  the  typical  symp- 
toms of  a  tumor  involving  in  large  part  one  lateral 
lobe  of  the  cerebellum,  and  therefore  one  of  the 
most  desirable  cases  for  operation,  was  greatly 
benefited  so  far  as  the  focal  symptoms  of  a  cere- 
bellar tumor  and  the  general  symptoms  of  an 
intracranial  growth  were  concerned.     Her  head- 


91 


ache,  nausea,  vomiting,  and  vertigo  disappeared 
in  spite  of  her  almost  total  blindness;  her  ataxia 
was  also  almost  entirely  relieved.  The  optic  neu- 
ritis had  advanced  to  such  a  degree,  even  before 
she  was  admitted  to  the  hospital,  that  operation 
did  not  save  her  from  blindness,  although  sur- 
gical procedure  was  adopted  about  ten  days  from 
the  time  of  her  admission. 

Case  II.— Tumor  of  left  lateral  lobe  of  the 
cerebellum;  operation;  recovery;  relapse. 

F.  M.,  ten  years  old,  was  referred  to  the  Uni- 
versity Hospital  by  Dr.  D.  J.  McCarthy,  with  a 
diagnosis  of  tumor  of  the  cerebellum,  and  was 
admitted  to  the  wards  of  Dr.  Frazier,  March  7, 
1904.  After  admission  to  the  hospital  he  was 
seen  in  consultation  by  Dr.  William  G.  Spiller 
and  also  by  Dr.  Mills. 

One  point  of  interest  in  the  family  history  was 
the  fact  that  one  brother  of  the  patient  had  some 
pulmonary  disease,  chronic  in  character.  The  pa- 
tient, up  to  the  time  of  his  present  illness,  had 
been  a  healthy  child,  had  gone  to  school  at  the 
age  of  six  years,  and  had  been  able  to  keep  up 
with  his  classmates. 

Toward  the  end  of  December,  1903,  the  mother 
noticed  that  the  boy  was  not  as  lively  as  before, 
and  that  he  stayed  in  the  house  in  preference  to 
going  out  of  doors.  She  took  him  to  the  Epis- 
copal Hospital,  where  he  was  treated  for  a  cough. 
At  this  time  he  had  lost  some  weight  and  was 
generally  run  down  in  health.  After  treatment 
he  improved,  gaining  weight,  but  he  was  un- 
steady in  walking. 


92 

About  the  middle  of  January,  1904,  the  boy  be- 
gan to  suffer  from  severe  headaches,  apparently 
causeless,  these  being  accompanied  by  vertigo. 
At  this  time  the  patient  held  his  head  up  straight 
and  avoided  stooping,  fearing  increased  dizziness. 
During  two  or  three  weeks  vomiting  had  been 
added  to  his  other  symptoms,  this  occurring  two 
or  three  times  a  week.  Evacuation  of  the  con- 
tents of  the  stomach  did  not  bring  relief. 

At  about  the  time  of  his  admission  it  was  noted 
that  he  had  not  had  any  convulsions,  that  his 
hearing  was  unaffected,  that  he  had  not  com- 
plained of  interference  with  vision,  that  a  grad- 
ual increasing  ataxia  was  present,  and  also  that 
his  headache,  vertigo,  and  vomiting  were  aug- 
menting. 

The  analysis  of  his  urine  showed  no  albumin, 
casts,  or  sugar,  and  a  specific  gravity  of  1.018,  the 
examination  being  practically  negative. 

Examination  showed  that  his'  mental  state  was 
distinctly  that  of  lassitude;  he  was  drowsy,  took 
little  notice  of  his  surroundings,  and  manifested 
when  examined,  a  degree  of  impatience  which 
was  almost  irritation.  General  physical  exam- 
ination of  heart,  stomach,  and  other  viscera 
showed  nothing  of  special  importance,  except  of 
the  lungs  as  given  below. 

The  respiratory  excursions  were  of  fair  ampli- 
tude, apparently  equal  on  both  sides.  The  per- 
cussion note  showed  an  impairment  over  the  left 
apex  down  to  the  third  rib.  Over  this  area  faint 
crepitant  rales  were  heard  on  inspiration.  Ex- 
piration    was     prolonged,     somewhat     blowing. 


93 

• 

Fremitus,  both  local  and  tactile,  were  slightly  in- 
creased. Various  examinations  showed  ataxia, 
this  present  to  some  extent  in  the  upper  extremi- 
ties as  well  as  markedly  present  in  the  lower.  No 
Romberg  sign  was  noted.  The  examination  by 
Dr.  Spiller  given  below  covers,  however,  the  im- 
portant points  in  his  neurological  symptomatol- 
ogy. His  pupils  were  dilated  and  there  was  a 
suggestion  of  photophobia. 

The  patient  complained  of  severe  headache, 
locating  the  pain  in  the  frontoparietal  region. 
Tapping  with  the  finger  elicited  pain  all  over  the 
head,  this  being  especially  marked  over  the  tem- 
peroparietal  portion  on  the  left.  No  scars  or 
other  evidences  of  injury  were  discovered. 

Shortly  after  admission  while  suffering  from 
severe  headache,  the  patient's  pulse  became  ex- 
ceedingly irregular,  both  as  to  volume  and 
rhythm,  and  its  rate  was  greatly  decreased  and 
weakened. 

Eye  examination  of  the  patient  was  made  by 
Dr.  G.  E.  de  Schweinitz  and  Dr.  John  T.  Carpen- 
ter. The  examination  made  March  8th  showed 
the  following :  V.  of  O.  D.  V^,  of  O.  S.  V^.^.  The 
amplitude  of  accommodation  of  each  eye  is  12  D. 
The  pupils  are  round  and  the  irides  react  prompt- 
ly to  light  and  accommodation  and  convergence. 
With  the  exception  of  a  slight  esophoria,  there  is 
no  defect  of  muscle  balance  and  no  diplopia.  The 
ophthalmoscope  reveals  the  following  conditions : 
Right  eye  papillitis  (choked  disc),  the  apex  of 
the  swelling  being  4  D.,  the  vessels  on  the  sur- 
face of  the  disc  i^  D.  higher.     The  nerve  edges 


94 

are  entirely  obscured.  The  surrounding  retina  is 
not  involved.  In  the  left  eye  there  is  an  exactly 
similar  swelling  of  the  disc,  with  the  exception 
that  its  riasal  edge  is  more  involved.  There  is  a 
moderate  concentric  contraction  of  each  visual 
field,  more  marked  upon  the  left  than  upon  the 
right  side. 

Examination  by  Dr.  Spiller  on  March  9th 
showed  the  following:  The  tenderness  of  the  scalp 
to  percussion  formerly  noted  had  disappeared. 
He  held  his  head  retracted,  because  he  said  it 
caused  him  pain  to  hold  it  straight.  There  was 
no  distinct  rigidity  of  his  neck;  movements  of 
the  head  were  free  in  all  directions ;  passive  move- 
ments caused  headache.  The  movements  of  the 
eyeball  were  free  in  all  directions ;  some  nystag- 
moid movements  were  present  when  looking  to 
the  extreme  right  or  left.  The  fifth  and  seventh 
nerves  were  not  involved  on  either  side.  The 
tongue  showed  a  slight  tendency  to  deviate  to  the 
right  when  protruded;  no  distinct  fibrillary  tre- 
mors of  the  tongue  were  noted. 

The  grasp  of  each  hand  was  fair  and  equal  on 
both  sides.  The  finger  to  nose  test  did  not  re- 
veal distinct  ataxia.  The  upper  limbs  were  slightly 
but  not  distinctly  atrophied.  The  biceps,  triceps, 
and  wrist  reflexes  were  not  distinct  on  either  side. 
The  voluntary  movements  of  the  upper  limbs 
were  normal.  There  was  no  loss  of  sensation  to 
touch  or  pain.  The  muscles  of  the  trunk  were 
fairly  well  developed. 

The  voluntary  movements  of  the  lower  limbs 
showed  normal  muscular  power  and  no  wasting. 


95 

The  patellar  reflex  was  lost  on  both  sides;  even 
when  sitting  on  the  edge  of  the  bed  with  reinforce- 
ment there  was  no  response.  The  Achilles  jerk 
was  not  present  on  either  side ;  the  Babinski  re- 
flex could  not  be  obtained  on  either  side;  there 
was  no  ankle  clonus.  The  heel  to  knee  test  did 
not  reveal  ataxia.  Sensation  for  touch  and  pain 
was  normal.  At  the  time  of  this  examination  the 
gait  was  not  ataxic  with  eyes  open ;  it  was  slight- 
ly so  when  the  eyes  were  closed.  There  was  no 
sway  when  standing  erect,  either  with  the  eyes 
open  or  closed.  No  hemiasynergia  was  present 
on  either  side ;  Koenig's  sign  was  also  absent  on 
both  sides.  The  operation  was  performed  by  Dr. 
Frazier  on  March  13,  1904.  The  bone  overlying 
the  left  lobe  of  the  cerebellum  was  very  thin  and 
the  dura  was  unusually  tense.  Immediately  after 
the  dura  was  opened  the  hemisphere  protruded  to 
a  much  greater  degree  than  usual.  No  adhesions 
were  found  either  between  the  skull  and  dura  or 
between  the  dura  and  cerebellum.  The  latter  did 
not  pulsate.  A  thorough  exploration  of  the  left 
hemisphere  failed  to  reveal  the  presence  of  a  tu- 
mor. As  a  palliative  procedure  one  third  of  the 
cerebellar  hemisphere  was  removed.  The  pa- 
tient's condition  immediately  after  the  operation 
caused  some  anxiety,  but  after  intravenous  injec- 
tion and  mild  stimulation  the  patient  improved 
rapidly  and  spent  a  comfortable  night.  The 
wound  healed  by  first  intention.  On  March  27th 
the  patient's  condition  was  noted  as  being  greatly 
improved.     His  whole  disposition  had  changed ; 


96 


he  was  bright  and  cheerful  and  complained 
neither  of  headache  nor  vomiting. 

In  November,  1904,  the  patient  returned  to 
the  hospital,  because  of  recurrence  of  some  of 
the  symptoms.  On  the  following  day  an  incision 
was  made,  following  the  line  of  the  old  cicatrix, 
and  an  infiltrating  tumor  of  about  the  size  of  a 
walnut  was  found  in  the  hemisphere,  apparently 
taking  its  origin  from  some  point  near  the  cere- 
bellopontile  angle.  The  patient  reacted  prompt- 
ly after  the  operation,  the  wound  healed  by  first 
intention  throughout,  and  convalescence  was  un- 
interrupted. The  tumor  was  a  glioma.  After 
the  notes  of  the  case  were  sent  to  the  press  the 
patient  relapsed,  showing  that  the  growth  was 
probably  infiltrating  and  had  not  been  fully  re- 
moved. 

Eye  examination  made  after  the  operation  by 
Dr.  G.  E.  de  Schweinitz  and  Dr.  J.  T.  Carpenter, 
March  14th.  The  condition  of  the  right  disc  is 
unchanged.  On  the  left  side  there  has  been  a 
subsidence  of  the  swelling,  which  is  now  3  D.  in 
place  of  4  or  43^  D. 

Case  III. — Tumor  of  the  cerebellum,  probably 
of  the  vermis  and  left  lateral  lobe ;  operation ;  tu- 
mor not  found;  recovery  from  operation,  with  re- 
lief of  symptoms. 

J.  H.,  forty-one  years  old,  was  admitted  to  the 
University  Hospital  March  6,  1902,  under  the  care 
of  Dr.  Mills  and  Dr.  Frazier.  No  history  of  nerv- 
ous or  tuberculous  disease  or  of  tumor  could  be 
ascertained,  but  an  aunt  had  suffered  from  can- 


97 

cer  of  the  face,  probably  dying  from  this  affec- 
tion.   The  patient  denied  syphilis. 

About  two  years  before  admission  to  the  hos- 
pital he  began  to  have  headache,  most  marked 
behind  the  eyes  and  in  the  temporal  regions.  His 
sight  also  began  to  fail  at  this  time,  and  his  gait 
became  unsteady,  he  tending  to  totter  or  fall  to 
the  right  side.  His  headache  improved  under 
treatment,  but  his  sight  and  gait  remained  the 
same. 

In  May,  1901,  he  had  a  crisis  of  vomiting,  which 
lasted  for  about  a  week ;  he  vomited  almost  daily, 
immediately  after  eating,  there  being  little  retch- 
ing or  straining  accompanying  the  vomiting.  The 
left  leg  at  this  time  seemed  weaker  than  the  right. 
His  bowels  were  constipated,  and  were  moved  by 
laxatives  daily  for  two  years  before  he  came  to 
the  hospital.  He  had  no  pain  in  the  anus  or  in 
the  legs.  He  was  not  paralyzed  and  had  no  vesi- 
cal symptoms.  There  was  no  history  of  vertigo ; 
his  hearing  was  not  disturbed  and  his  memory 
was  good.  On  rising  in  the  morning  he  had  on 
a  few  occasions  attacks  of  faintness  or  weakness, 
but  he  had  never  lost  consciousness. 

Examination  of  the  urine  two  days  after  ad- 
mission to  the  hospital  was  negative. 

Several  examinations  of  this  patient,  made  by 
Dr.  Mills  and  Dr.  Spiller  shortly  after  admission, 
gave  the  following  results:  Vertical  nystagmus 
was  present  when  the  eyes  were  at  rest  or  when 
they  looked  upward  or  downward,  the  nystagmus 
becoming  lateral  when  the  eyes  were  turned  to 
the  right  or  left.     The  patient  in  walking  took 


98 

short,  unequal  steps,  showing  a  lack  of  confi- 
dence ;  at  times  he  exhibited  a  tendency  to  go  to 
the  right.  In  standing  the  feet  were  kept  wide 
apart,  as  he  swayed  greatly  and  would  have  fallen 
if  not  supported  when  the  feet  were  together. 
The  sway  was  not  distinctly  increased  by  closure 
of  the  eyes.  Ataxia  was  present  in  the  left  upper 
extremity,  and  doubtfully  in  the  right.  Speech 
and  mental  response  were  both  slow.  The  tongue 
was  protruded  straight  and  without  fibrillary 
tremor.  The  knee  jerks  were  prompt,  the  left 
distinctly  exaggerated.  The  Achilles  jerk  was 
present  on  each  side.  Ankle  clonus  was  not  pres- 
ent on  the  right,  but  was  slightly  indicated  on  the 
left.  The  Babinski  reflex  was  not  present  on 
either  side,  the  movement  of  the  toes  being  that 
of  slight  flexion  on  both  sides. 

An  eye  examination  was  made  by  Dr.  Howard 
Mellor,  March  7th,  the  date  of  his  admission. 
Visual  acuity  and  the  amplitude  of  accommoda- 
tion were  not  recorded.  He  reported  the  follow- 
ing: The  pupils  are  equal  in  size  and  the  irides 
react  promptly  to  light  and  in  convergence.  The 
ophthalmoscope  reveals  the  following  conditions : 
A  low  grade  neuritis  with  involvement  of  the  sur- 
rounding retina  (neuroretinitis),  which  is  most 
marked  in  the  left  eye.  There  is  very  distinct  ver- 
tical nystagmus  when  the  patient  looks  directly 
forward,  and  extremely  marked  lateral  nystag- 
mus on  looking  to  either  side.  When  the  gaze  is 
directed  upwards  or  downwards,  the  vertical  nys- 
tagmus increases.  The  rotations  of  the  eyeballs 
are  normal  in  all  directions. 


99 

The  patient  left  the  hospital  and  was  readmit- 
ted on  October  9,  1902.  His  difficulty  in  walking 
had  gradually  increased  until  he  was  able  to  walk 
only  a  few  steps  with  a  cane,  and  at  times  he  fell. 
When  assisted  he  walked  by  raising  the  leg  and 
foot  high,  and  bringing  it  down  heavily.  His 
feet  were  always  wide  apart.  Ataxia  was 
marked.  He  had  not  vomited  since  leaving  the 
hospital.  The  nystagmus  was  the  same  as  on  the 
first  admission.  A  twitch  of  the  orbicular  mus- 
cle in  the  left  eye  was  noticeable  at  times.  He 
could  hear  a  watch  at  three  feet,  on  the  right  side, 
on  the  left  he  could  hear  it  at  a  distance  of  two 
inches.  He  had  no  tinnitus  or  other  abnormal 
sounds.  He  complained  of  no  trouble  with  the 
bladder  or  rectum.     He  had  no  astereognosis. 

Examination  by  Dr.  de  Schweinitz,  October  9, 
1902.— V.  of  O.  D.  V22,  of  O.  S.  V22.  The  patient 
reads  J.  2  at  33  cm,  with  each  eye.  The  pupils 
are  equal  and  respond  promptly  to  light  and  con- 
vergence. The  nystagmus  recorded  in  the  pre- 
vious examination  continues  unchanged.  The 
ophthalmoscope  reveals  the  following  conditions : 
The  right  optic  nerve  is  beginning  to  be  atrophic, 
the  vessels  being  reduced  in  calibre,  and  there  is 
an  area  of  atrophy  of  the  chorioid  surrounding  the 
nerve  head.  In  the  left  eye  a  moderate  neuritis 
with  indications  of  beginning  atrophy  is  evident. 

No  atrophy,  rigidity,  contractures,  or  spasticity 
was  present  in  the  lower  extremities  on  either 
side.  Late  in  the  case  the  muscles  of  mastica- 
tion were  normal  on  the  right,  and  distinctly 
weak,  although  not  paralyzed  fully,  on  the  left. 


100 

When  the  mouth  was  opened  the  jaw  tended  to 
go  slightly  toward  the  left.  Sensation  was  unim- 
paired everywhere.  No  hemiasynergia  was  pres- 
ent on  either  side. 

The  prominent  symptoms  in  this  case  just  be- 
fore the  operation  were  secondary  optic  atrophy, 
headache  and  vomiting,  nystagmus,  cerebellar 
gait,  exaggerated  reflexes,  deafness  on  the  left 
side,  weakness  of  the  left  motor  fifth,  and  prob- 
ably some  weakness  of  the  soft  palate  on  the  left 
side. 

October  25,  1902,  the  patient  was  operated  upon 
by  Dr.  Frazier.  Upon  the  left  side  of  the  head 
a  horseshoe-shaped  flap  was  reflected,  the  inci- 
sion beginning  at  the  tip  of  the  mastoid  process 
following  the  superior  curved  line,  and  termi- 
nating in  the  median  line  of  the  neck,  opposite 
the  spinous  process  of  the  second  cervical  ver- 
tebra. The  skull  was  opened  as  usual  with  a 
chisel  and  mallet,  and  the  opening  enlarged  with 
a  rongeur  forceps.  There  was  an  escape  of  a 
moderate  amount  of  cerebrospinal  fluid.  Inspec- 
tion and  palpation  of  the  cerebellar  hemisphere 
revealed  no  abnormity.  There  was  no  thicken- 
ing of  the  meninges,  no  alteration  in  color  or  con- 
sistence of  the  cerebellar  tissue.  It  was  deemed 
inadvisable  to  make  any  further  inspection  and 
the  wound  was  closed.  The  patient  recovered 
from  the  effects  of  the  operation,  and  declined 
any  other  intervention,  although  Dr.  Mills  and 
Dr.  Frazier  advised  an  exploratory  operation 
upon  the  opposite  side. 


101 

Case  IV. — Tumor  of  the  cerebellum  or  cere- 
bellopontile  angle ;  tumor  not  found,  but  lateral 
lobe  partly  excised  with  great  benefit. 

G.  E.,  twenty-three  years  of  age,  was  referred 
to  Dr.  Mills  for  opinion  and  treatment.  When 
the  patient  presented  himself  to  the  hospital  he 
was  suffering  from  most  distressing  headache, 
which  was  almost  constant,  and  from  vertigo  and 
ataxia,  to  such  an  extent  that  it  was  impossible 
for  him  to  walk  alone  or  without  support.  Nor 
could  he  even  stand  alone,  unless  leaning  against 
some  stationary  object.  His  vision  was  so  af- 
fected that  he  could  not  see  gross  objects,  and 
examination  of  his  eye  grounds  revealed  the  pres- 
ence of  very  marked  choked  discs  and  optic  neu- 
ritis. 

The  patient  was  suffering  to  such  an  extent 
that  it  did  not  seem  justifiable  to  postpone  oper- 
ation for  further  and  more  elaborate  study  of  the 
case.  Accordingly  within  a  week  of  his  admis- 
sion to  the  hospital  a  left  cerebellar  craniectomy 
was  performed  by  Dr.  Frazier.  The  dura  was 
noted  to  be  unusually  tense,  and  upon  reflecting 
the  dural  flap  a  considerable  portion  of  the  cere- 
bellar hemisphere  protruded  through  the  open- 
ing. It  was  found  to  be  almost  impossible  on  ac- 
count of  the  protrusion  of  cerebellar  tissue  to 
make  further  exploration,  so  the  operator  pro- 
ceeded to  remove  from  one  third  to  one  half  of 
the  lateral  lobe.  After  this  was  accomplished  ex- 
ploration was  continued,  but  to  no  avail.  No  tu- 
mor could  be  seen  or  be  felt  in  any  portion  of  the 
left  cerebellar  fossa.    The  postoperative  record  of 


102 

this  patient  is  one  of  unusual  interest,  because  of 
the  remarkably  rapid  improvement  which  fol- 
lowed. Within  one  week  of  the  operation  the 
patient's  headache  had  entirely  disappeared,  his 
vision  was  restored  so  that  he  could  see  minute 
objects  on  the  ceiling  as  he  lay  in  bed,  and  his 
vertigo  and  ataxia  had  almost  entirely  disap- 
peared. At  no  time  during  the  convalescing  pe- 
riod was  the  patient's  condition  such  as  to  give 
any  concern.  He  was  kept  under  observation  in 
the  hospital  for  a  period  of  two  months,  and  inas- 
much as  there  was  not  the  slightest  return  of 
symptoms  he  was  allowed  to  go  home  with  the 
understanding  that  he  would  return  to  the  hos- 
pital if  any  of  his  cerebellar  symptoms  recurred. 

Case  V. — Tumor  probably  of  the  cerebellum 
involving  the  vermis  and  right  lateral  lobe ;  oper- 
ation in  two  stages  planned;  death  from  haemor- 
rhage from  bony  sinuses  twelve  hours  after  first 
operation. 

J.  C,  fifteen  years  old,  was  referred  by  Dr. 
Samuel  Freeman  and  Dr.  Frank  V.  Cantwell,  of 
Trenton,  N.  J.,  to  Dr.  Mills  for  opinion  and  treat- 
ment. He  had  a  history  that  fifteen  months  be- 
fore coming  under  observation  he  had  begun  to 
suffer  with  headache,  this  having  been  preceded 
by  dizziness ;  he  also  began  to  suffer  from  vomit- 
ing six  months  before,  and  exhibited  a  staggering 
gait  one  month  later.  The  attacks  of  headache, 
dizziness  and  nausea  and  vomiting  increased  in 
frequency  and  in  severity,  and  the  uncertainty 
of  gait  became  steadily  more  and  more  marked. 

When  the  patient  was  first  examined  it  was 


103 

found  that  he  was  suffering  intensely  from  head- 
ache, which  was  almost  continuous,  while  his  diz- 
ziness, nausea,  and  vomiting  were  of  frequent  oc- 
currence. 

The  eye  examination  made  by  Dr.  G.  E.  de 
Schweinitz,  July  5,  1904,  resulted  as  follows:  V. 
of  O.  D.  V9J  of  O.  S.  ^/g.  Amplitude  of  accom- 
modation markedly  defective,  the  patient  being 
able  to  read  only  D.  =  i  at  18  cm.  The  pupils 
are  large,  but  their  reactions  are  normal.  There 
is  paresis  of  the  left  external  rectus  muscle,  and 
lateral  nystagmus  develops  when  the  eyes  are 
directed  to  the  left,  that  is  to  say,  in  laevoversion. 
The  ophthalmoscope  reveals  the  following  con- 
ditions :  In  the  right  eye  papillitis,  the  apex  of  the 
swelling  being  3  D.  It  is  vascular  in  the  extreme, 
but  the  centre  of  the  disc  is  not  markedly  filled  in. 
The  veins  are  full  and  carry  very  dark-colored 
blood.  There  is  no  macular  figure.  In  the  left 
eye  the  papillitis  is  greater  than  on  the  opposite 
side,  the  apex  of  the  swelling  being  5  D.  with 
decided  engorgement,  and  the  appearance  to 
which  the  name  choked  disc  is  ordinarily  given. 
The  veins  are  even  fuller  and  darker  than  upon 
the  other  side.  The  peripheral  visual  field  for 
form  of  each  eye  is  normal.  There  are  no  scoto- 
mas. 

Comment. — The  double  optic  neuritis  (choked 
disc),  together  with  paresis  of  the  left  external 
rectus  muscle  and  lateral  nystagmus,  especially 
when  the  eyes  are  directed  towards  the  left,  are 
ocular  signs  frequently  seen  in  cerebellar  dis- 
eases. 


104 

At  one  examination  it  was  noted  that  in  stand- 
ing or  walking  the  patient  was  markedly  ataxic 
and  asthenic,  always  tending  to  the  right,  and 
that  ataxia,  less  marked,  was  present  also  in  the 
upper  extremities  as  determined  by  having  him 
touch  his  nose  with  the  finger  and  in  other  ways. 
This  ataxia  was  doubtfully  more  marked  on  the 
right.     Hemiasynergia  was  not  present. 

His  mental  condition  was  good,  except  in  so 
far  as  he  was  irritated,  depressed  and  worried  by 
the  pain. 

His  muscles  were  flaccid  and  atonic.  There 
was  no  distinct  paralysis  of  the  extremities,  but 
his  head  showed  some  tendency  to  drop  back- 
wards, especially  when  he  would  look  upward. 
This  was  probably  due  to  weakness  of  the  sup- 
porting muscles  of  the  neck. 

At  a  second  examination  a  few  days  later  it  was 
noticed  that  he  swayed  markedly  to  the  right, 
standing  with  eyes  shut  and  considerably  with 
eyes  open.  He  invariably  staggered  or  tended 
to  the  right  in  walking,  his  gait  being  somewhat 
titubating.  There  was  some  ataxia  in  both  arms, 
possibly  a  little  more  on  the  right.  No  hemi- 
asynergia was  present.  Tremor  was  marked  in 
both  upper  extremities,  a  little  more  so  on  the 
left;  it  was  coarse,  jerky  and  increased  by  action. 
The  muscular  sense  was  preserved,  as  was  also 
stereognostic  perception.  The  right  side  of. the 
face  was  apparently  hypassthetic,  as  were  also 
the  arm  and  leg  of  the  same  side.  This  symp- 
tom, however,  seemed  variable  or  doubtful,  as 
the  patient  did  not  always  answer  in  the  same 


105 


way  as  regards  the  impression  made.  The  head 
was  not  carried  towards  either  shoulder,  but,  as 
stated  above,  sometimes  it  had  a  tendency  to 
droop  or  fall  backwards.  Both  knee  jerks  were 
plus.  The  Babinski  response  was  absent  on  each 
side.  Incontinence  of  urine  or  faeces  was  not 
present. 

Paresis  of  the  left  external  rectus,  with  nystag- 
moid movements  when  the  eyes  are  turned  far 
to  the  left,  was  present ;  no  such  movements  were 
shown  when  the  head  was  turned  to  the  right  up- 
wards or  downwards.  When  the  patient  fol- 
lowed the  finger  with  his  eyeballs  von  Graefe's 
sign  was  very  distinct.  About  }i  inch  and  pos- 
sibly even  more  of  the  white  of  the  eyeball  was 
seen  between  the  iris  and  the  upper  lid  on  each 
side. 

The  knee  jerks  were  slightly  plus;  the  ankle 
jerks  about  normal;  the  muscle  jerks  a  little  be- 
low normal.  The  tongue  was  protruded  straight 
and  was  not  atrophied.  It  exhibited  no  fibrillary 
tremor. 

Speech  was  a  little  peculiar,  but  the  patient 
said  that  it  had  always  been  the  same  as  it  was 
at  this  time. 

According  to  Dr.  B.  A.  Randall's  report,  the 
patient  had  nearly  normal  ears  in  appearance -and 
function  with  possibly  a  trace  of  tympanitic  re- 
duction of  hearing;  the  auditory  nerves  seemed 
to  be  in  perfect  condition. 

There  was  no  thyreoid  or  other  glandular  en- 
largement of  the  neck.  The  thorax  was  small, 
narrow,  and  poorly  shaped  and  developed;  the 


106 


supraclavicular  and  infraclavicular  spaces  were 
prominent ;  the  expansion  was  poor.  In  front 
and  back  of  the  lungs  the  breath  sounds  were 
clear  but  faint.  The  action  of  the  heart  was  regu- 
lar; there  were  no  murmurs.  The  abdomen  was 
flat. 

The  patient  came  under  observation  July  6, 
1904,  and  was  admitted  the  same  day  to  the  Uni- 
versity Hospital,  where  he  was  seen  by  Dr.  Spil- 
ler  in  consultation  with  Dr.  Mills.  The  diagnosis 
of  tumor  of  the  cerebellum  probably  involving 
the  right  lateral  lobe,  was  made. 

The  operation  was  performed  by  Dr.  Frazier 
July  9,  1904,  with  the  object  of  exposing  the  right 
lateral  lobe  of  the  cerebellum.  The  usual  inci- 
sion was  made  and  the  skull  opened  in  the  cus- 
tomary way.  Upon  reflection  of  the  musculo- 
cutaneous flap,  two  large  anomalous  sinuses  were 
exposed,  making  their  exit  at  a  point  about  2  cm. 
from  the  occipital  protuberance  and  a  little  be- 
low the  superior  curved  line.  The  blood  poured 
out  from  these  sinuses  in  great  quantities,  and 
every  attempt  which  was  made  to  control  the 
haemorrhage  by  pressure,  Horsley's  wax,  etc., 
failed,  until  some  small  plugs  of  wood,  made  from 
swab  sticks,  were  driven  into  the  bone.  By  this 
time  the  patient  had  lost  a  considerable  amount  of 
blood,  and  was  evidently  suffering  from  its  effect. 
Stimulation  was  resorted  to ;  a  hypodermic  of 
strychnine  was  given  and  a  pint  of  i  to  50,000 
adrenalin  salt  solution  was  administered  intra- 
venously. By  this  time  the  blood  pressure  had 
fallen  to  55,  and  for  the  next  fifteen  minutes  re- 


107 


mained  at  50.  It  then  fell  to  a  point  too  low  to 
estimate,  and  another  pint  of  i  to  50,000  adrenalin 
salt  solution  was  given  intravenously.  In  twenty- 
five  minutes  the  blood  pressure  rose  to  100,  and 
the  adrenalin  was  discontinued.  The  blood  pres- 
sure began  to  fall  again  and  resort  was  had  again 
to  intravenous  injections  of  adrenalin.  Owing  to 
the  excessive  hsemorrhage  it  was  decided  to  post- 
pone the  actual  exploration  for  the  tumor  until 
the  patient  had  fully  reacted.  The  operation  was 
performed  at  2  p.  m.,  and  from  that  on  to  i  a.  m. 
on  the  following  morning  the  patient's  condition 
gradually  improved.  At  i  a.  m.  his  pulse  was 
only  96  and  of  fair  volume.  His  color  good  and 
his  respirations  were  15.  At  1.15  a.  m.  his  pulse 
was  98,  and  his  respirations  were  14.  At  1.30 
a.  m.  his  condition  was  reported  as  unchanged, 
with  the  exception  that  his  respirations  had 
dropped  to  11.  At  1.40  a.  m.,  without  any  warn- 
ing, the  pulse  suddenly  shot  up  to  120,  respira- 
tions dropped  to  four.  The  patient  became 
cyanotic  and  died  at  1.45  a.  m.  No  autopsy  was 
permitted. 

It  is  difficult  to  account  for  the  death  of  this 
patient.  One  can  hardly  attribute  it  to  the  ex- 
cessive haemorrhage  at  the  time  of  the  operation, 
although  this  may  have  been  a  contributory 
cause.  The  condition  of  the  pulse  and  blood 
pressure  showed  that  the  patient  had  almost  fully 
reacted  soon  after  the  operation.  The  slow  re- 
spiratory rate  suggests  the  possibility  of  an  in- 
jury to  the  respiratory  centre,  although  this  would 
hardly  have  been  inflicted  by  any  step  in  the  oper- 


108 

ation,  inasmuch  as  no  attempt  was  made  to  ex- 
plore the  cerebellar  fossa. 

Case  VI. — Cerebellopontile  operation  for  tu- 
mor of  pons ;  probable  second  lesion  in  parietal 
lobe;  cyst  evacuated;  permanent  disappearance 
of  severe  headache  and  facial  neuralgia. 

This  patient,  a  woman,  about  forty-five  years 
old,  first  came  under  the  care  of  Dr.  Mills  in 
November,  1902.  One  year  before  coming  un- 
der observation  she  had  an  attack  of  vertigo  with- 
out unconsciousness  and  after  this  partial  paraly- 
sis of  the  left  third  nerve  was  observed,  ptosis,  di- 
lated pupil  and  paresis  of  the  internal  rectus  be- 
ing present,  according  to  the  physician  then  in 
attendance.  She  also  appeared  from  the  history 
to  have  had  temporary  paralysis  of  the  left  side 
of  the  face.  She  had  subsequent  similar  attacks, 
some  of  these  shortly  before  coming  under  obser- 
vation. In  one  of  the  recent  seizures  she  was 
found  in  the  cellar,  pacing  up  and  down  with  her 
hands  above  her  head,  eyes  dilated  and  apparently 
struggling  against  suffocation.  She  was  taken 
upstairs  and  put  to  bed ;  she  tried  to  speak,  mov- 
ing her  jaws  without  uttering  any  sound;  her 
face  was  pale,  her  eyes  were  open.  At  the  time 
of  the  first  examinations  she  had  paresis  of  the 
left  side  of  the  face,  partial  ptosis,  pupils  equal 
and  responsive,  the  superior  rectus  not  being  as 
active  on  the  left  side  as  on  the  right. 

In  the  fall  of  1902  the  patient  was  under  the 
care  of  Dr.  Mills  in  a  private  hospital.  During 
this  period  her  chief  symptoms  were  occasional 
headache,  general  nervousness,  and  at  times  slight 


109 


mental  confusion.  The  partial  palsies  of  the 
third  and  seventh  nerves  as  above  noted  were 
present. 

In  the  summer  of  1903  she  went  to  a  mountain 
resort,  and  while  there  she  had  an  attack  of  con- 
vulsions, after  which  she  had  partial  paralysis  in 
the  right  half  of  the  body.  The  physician  called 
in  to  see  the  patient  because  of  the  attack  of 
spasm,  wrote  to  me  as  follows  regarding  his 
observations : 

"  When  I  saw  the  patient  she  was  in  a  semi- 
comatose state,  and  from  superficial  observation 
and  the  history  given  I  thought  that  I  had  a  hys- 
terical condition.  A  dose  of  potassium  bromide 
aroused  her  from  the  stupor  following  the  convul- 
sions, which,  with  the  stupor,  had  lasted  eight 
or  ten  hours.  The  spasms  had  not  been  espe- 
cially pronounced,  and  had  subsided  some  three 
hours  previous,  with  the  exception  of  some  twitch- 
ing around  the  mouth.  From  the  account  given, 
the  contractions  were  alike  on  each  side,  and  at 
the  time  of  my  visit  no  paralysis  was  present, 
although  it  was  stated  that  at  some  previous 
time  she  had  had  left-sided  paralysis,  but  not 
in  this  attack.  Mentally  she  was  unbalanced. 
She  seemed  to  grasp  the  purport  of  a  ques- 
tion, but  generally  gave  meaningless  answers. 
She  was  hunting  for  some  imaginary  thing 
which  she  had  lost,  and  every  moment  or 
two  earnestly  asked  the  time  of  day.  On  at- 
tempting to  arise  in  the  morning,  she  fell  from 
the  bed,  prone,  evidently  the  commencement  of 
her  convulsive  attack.     Inquiry  elicited  the  fact 


no 

that  there  had  been  some  previous  brain  lesion, 
which  I  could  not  definitely  locate,  but  the  knowl- 
edge of  which,  with  the  other  symptoms,  ex- 
cluded the  idea  of  hysteria." 

When  seen  shortly  after  this,  in  addition  to 
the  symptoms  already  noted,  she  also  showed 
some  amnesia  for  names,  and  some  mental  change 
or  weakening  hard  to  describe  and  complained 
much  of  headache.  Ophthalmoscopic  examina- 
tion made  about  this  time  by  Dr.  S.  D.  Risley 
showed  no  optic  neuritis,  but  bad  eye  grounds, 
probably  due  to  eye  strain. 

An  eye  examination  was  made  by  Dr.  G.  E.  de 
Schweinitz  on  September  lo,  1903,  who  reported 
as  follows :  V.  of  O.  D.  V^,  of  O.  S.  V5.  Ampli- 
tude of  accommodation,  4  D.  The  pupils  are 
round  and  react  normally  to  light,  accommoda- 
tion and  convergence.  There  is  slight  ptosis  of 
the  left  eye  and  paralysis  of  the  left  inferior  rectus 
muscle.  The  ophthalmoscope  reveals  the  follow- 
ing conditions :  Both  optic  nerves  are  round,  their 
nasal  and  upper  edges  being  veiled.  The  central 
lymph  sheaths  are  fuller  than  normal  and  the 
veins  somewhat  overdistended.  This  is  particu- 
larly true  of  the  lower  temporal  vein  of  the  left 
side.  The  veiling  of  the  disc  edges  is  evident,  as 
well  by  indirect  as  by  direct  method  of  ophthal- 
moscopy, and  taken  into  consideration  with  the 
overcapillarity  of  the  disc  surface,  may  be  re- 
garded as  indicating  a  congestion  of  the  nerve 
heads.  Actual  neuritis  is  not  present,  as  there  is 
no  swelling  of  the  papillae.  The  visual  fields  are 
normal. 


Ill 

The  patient  was  examined  by  Dr.  Mills,  Dr. 
Dercum,  and  Dr.  Spiller  in  consultation  on  Sep- 
tember II,  1903.  Resistance  to  passive  move- 
ments in  the  lower  limbs  was  about  equal.  Knee 
jerks  were  much  exaggerated  on  both  sides ;  ankle 
clonus  was  easily  obtained  and  persistent  on  the 
right;  it  was  faint  and  not  persistent  on  the  left. 
Her  station  was  erect  and  normal  with  eyes  open. 
She  swayed  distinctly  with  eyes  closed,  the  sway 
being  greater  towards  the  right.  Her  gait  was  a 
little  uncertain,  much  more  so  with  the  eyes 
closed.  She  showed  a  slight  tendency  to  drag 
the  right  foot  as  if  it  stuck  to  the  floor.  In  walk- 
ing backward  with  her  eyes  closed  she  put  the 
left  foot  backward  and  drew  the  right  foot  to  it. 
The  Babinski  reflex  was  doubtfully  present  on 
the  right  side,  but  was  not  obtained  at  all  on  the 
left,  the  toes  responding  by  plantar  flexion. 
When  a  pencil  was  laid  lengthwise  or  crosswise 
on  either  foot  she  was  unable  to  give  the  correct 
position;  the  position  seemed  to  her  usually  as 
being  across  the  toes.  Touch  was  felt  every- 
where, but  distinctly  better  in  the  upper  and  lower 
limbs  on  the  left  side  and  on  the  left  side  of  the 
face  than  in  the  corresponding  parts  of  the  right 
side.  Pain  stimulus  was  felt  everywhere,  but  like 
tactile  sensation  was  more  distinct  in  the  left 
upper  and  lower  limbs  and  left  side  of  the  face. 
Sensation  for  cold  and  heat  Vv^as  everywhere  nor- 
mal. 

The  grasp  of  the  right  hand  was  distinctly 
weaker  than  that  of  the  left.  The  fingers  of  the 
right  hand  were  kept  partially  flexed  at  the  junc- 


112 

tion  of  the  second  and  third  phalanx,  the  thumb 
extended.  She  could  fully  extend  the  fingers, 
with  the  exception  of  the  middle  one.  Appos- 
ing the  thumb  to  the  little  finger  on  the  right  hand 
was  very  difficult.  Triceps  tendon  jerks  and 
wrist  reflexes  were  exaggerated  on  each  side,  dis- 
tinctly more  so  on  the  right  than  on  the  left.  The 
palm  of  the  right  hand  was  a  little  puffy,  but  not 
distinctly  cedematous.  She  could  raise  the  right 
upper  limb  to  the  full  extent  above  the  head ;  re- 
sistance to  passive  movements  was  much  im- 
paired in  the  right  upper  limb.  She  experienced 
difficulty  in  placing  the  first  finger  of  the  right 
hand  on  the  nose,  usually  carrying  it  to  one  side 
of  the  nose.  She  was  uncertain  as  to  the  posi- 
tion of  her  little  finger  when  it  was  raised,  usually 
saying  it  was  the  ring  finger ;  she  knew  the  other 
fingers  on  the  right  hand  when  they  were  raised. 
Stereognostic  perception  was  greatly  impaired  on 
the  right  hand  and  not  on  the  left.  She  could  not, 
for  instance,  recognize  a  knife,  pencil,  or  other 
object  in  the  right  hand,  but  recognized  them 
promptly  in  the  left.  The  sense  of  position  of 
the  toes  of  both  the  right  and  the  left  foot  seemed 
to  be  preserved.  She  exhibited  a  slight  weakness 
in  drawing  up  the  right  corner  of  her  mouth,  but 
drew  the  left  side  up  better.  She  closed  her  eye- 
lids firmly  on  each  side,  and  wrinkled  her  fore- 
head well  and  equally  on  the  two  sides.  The 
tongue  was  protruded  straight  and  showed  fibril- 
lary tremor.  She  said  that  her  tongue  had  felt 
numb  and  stiff  for  two  days  before  the  examina- 
tion.    The  masseters  and  temporals  contracted 


113 

firmly  on  each  side.  She  heard  a  low  ticking 
watch  only  when  it  approached  to  within  about 
two  inches  of  either  ear,  the  hearing  seeming  to 
be  the  same  in  each  ear.  Sugar  and  salt  were 
tasted  promptly  on  each  side  of  the  tongue. 

Dr.  J.  W.  McConnell  examined  the  patient  on 
September  12,  1903,  and  reported  that  subsequent 
to  the  above  examination  she  had  an  attack  of 
twitching  of  the  right  arm  and  the  right  leg  with 
unconsciousness.  There  were  no  changes  from 
the  examination  of  the  previous  day.  She  com- 
plained of  intense  pain  in  the  left  parietal  region, 
and  also  said  that  she  had  some  numbness  in  the 
left  arm  and  leg. 

After  this  she  was  seen  from  time  to  time  by 
Dr.  Mills,  and  on  several  occasions  for  him  by 
Dr.  T.  H.  Weisenburg,  who  made  a  few  notes  as 
follows :  September  14,  1903.  Paresis  of  the  left 
internal  rectus  was  present.  Astereognosis  was 
not  present  in  the  right  hand,  and  the  sense  of 
position  of  the  right  hand  was  normal. 

September  16,  1903. — She  had  a  left-sided  peri- 
pheral facial  palsy,  also  a  paresis  of  the  left  ex- 
ternal rectus  and  of  the  internal  rectus.  No  sen- 
sory changes  were  present  on  the  left  side. 

The  patient  was  again  examined  by  Dr.  Mills 
and  Dr.  Spiller  on  September  22,  1903.  The  left 
side  of  the  face  was  paralyzed  in  the  entire  dis- 
tribution of  the  seventh  nerve.  She  complained 
of  much  pain,  confined  to  the  left  side  of  the  face 
and  in  the  distribution  of  the  fifth  nerve.  The 
masseter  and  temporal  muscles  contracted  well 
in  chewing  on  each  side.     No  distinct  objective 


114 

disturbance  of  sensation  on  the  left  side  of  the 
face  was  made  out.  The  left  external  rectus 
seemed  to  be  the  only  external  ocular  muscle  dis- 
tinctly paretic.  Astereognosis  in  the  right  hand 
was  almost  complete. 

She  complained  of  much  pain  on  both  sides  of 
the  forehead,  extending  down  the  left  side  of  the 
face  to  the  lower  border  of  the  lower  jaw.  The 
pain  did  not  extend  below  the  median  line  of  the 
lower  jaw;  it  extended  to  the  mastoid  process, 
but  not  beyond  this  on  the  left  side;  it  did  not 
extend  into  the  neck.  She  had  constant  pain  in 
both  temples,  but  it  was  greater  in  the  left  than 
in  the  right.  All  points  of  exit  of  the  fifth  nerve 
were  painful  to  pressure ;  as  much  so  on  the  right 
side  as  on  the  left.  Sensation  for  touch  and  for 
pain  on  the  two  sides  of  the  face  seemed  to  be 
normal;  she  felt  a  touch  or  pin  prick  as  well  on 
the  left  side  of  the  face  as  on  the  right.  In  such 
instances  as  when  chewing  a  hard  crust  of  bread, 
the  left  masseter  contracted,  but  not  so  well  as 
the  right;  in  opening  the  mouth  the  lower  jaw 
did  not  deviate  distinctly.  She  complained  of  a 
sense  of  numbness  in  the  left  side  of  the  face ;  this 
involved  the  entire  distribution  of  the  fifth  nerve 
and  extended  up  on  the  left  to  the  temple,  but  not 
far  beyond  the  border  of  the  hair.  There  was  con- 
siderable improvement  in  the  paralysis  of  the 
orbicularis  palpebrarum.  There  was  complete 
paralysis  in  the  lower  distribution  of  the  left 
facial  nerve.  The  right  side  of  the  face  was  nor- 
mal. 

She  did  not  have  any  nausea  and  seldom  had 


115 


spells  of  vertigo,  although  formerly  the  latter  oc- 
curred frequently.  She  showed  a  tendency  at 
times  to  fall  backwards  or  towards  the  left,  but 
did  not  stagger  as  much  as  formerly ;  closing  the 
eyelids  did  not  affect  the  gait  very  distinctly. 
Hemiasynergia  was  not  present  on  either  side. 

As  the  patient  was  slowly  getting  worse  and 
was  suffering  extremely  with  pain  in  her  head  and 
face,  it  was  finally  decided  to  remove  her  to  the 
University  Hospital  for  the  purpose  of  having  an 
operation,  which  might  at  least  be  palliative.  Her 
pain  increased  until  it  became  torturing,  and  for 
days  before  the  operation  it  was  necessary  to  keep 
her  continuously  under  the  effects  of  morphine 
or  codeine.  No  change  of  any  moment  occurred 
in  her  focal  symptoms  after  the  above  recorded 
notes. 

The  operation  was  performed  by  Dr.  Frazier 
on  October  14,  1903,  under  ether  anaesthesia.  A 
musculocutaneous  flap  together  with  the  perios- 
teum was  reflected  and  an  opening  was  made  in 
the  skull  with  the  chisel  and  enlarged  with  Ron- 
geur forceps.  Nothing  abnormal  as  regards  pul- 
sation nor  consistency  of  the  left  lateral  lobe  of 
the  cerebellum  was  noted.  The  dural  flap  was 
reflected;  at  one  point  this  flap  was  adherent  to 
the  underlying  brain.  Cerebellar  tissue  bulged 
only  moderately  through  the  wound.  On  explor- 
ing with  the  index  finger  in  the  region  of  the 
cerebellopontile  angle  some  adhesions  were  sep- 
arated on  the  lateral  aspect  of  the  cerebellum. 
This  was  followed  by  a  gush  of  fluid  which  had 
evidently  been  walled  off  by  adhesions.     After 


116 

the  evacuation  of  the  cyst  the  bulging  subsided 
immediately  and  with  a  brain  retractor  it  was 
possible  to  inspect  the  region  of  the  cerebello- 
pontile  angle  and  to  demonstrate  to  those  present 
at  the  operation,  the  fifth,  seventh,  and  eighth 
cranial  nerves.  It  was  noted  on  the  blood  pres- 
sure chart  that  when  the  dura  was  opened  the 
blood  pressure  dropped  thirty  points,  and  that 
upon  introducing  gauze  packing  or  upon  com- 
pressing the  brain  with  the  retractor  that  the 
blood  pressure  rose  forty  points.  The  patient's 
condition  was  not  depressed  to  any  considerable 
degree  by  the  operation ;  upon  her  return  to  bed 
her  pulse  was  145  ;  respirations  were  40,  and  blood 
pressure  was  115. 

The  interesting  feature  of  the  case  was  the  ease 
with  which  the  cranial  nerves  were  exposed  after 
the  cyst  had  been  evacuated. 

The  patient  reacted  well  after  the  operation 
and  passed  a  fairly  comfortable  night.  There  was 
very  profuse  oozing  of  blood  and  cerebrospinal 
fluid,  necessitating  frequent  reinforcement  of 
dressing.  The  patient  was  much  nauseated,  vom- 
iting curds  of  milk  and  bile  stained  fluid.  She 
complained  of  pain  in  her  temples.  A  hurried 
examination  showed  that  sensation  was  present 
on  both  sides  of  the  face  a'nd  no  inequality  of 
pupil  was  noted. 

On  October  15th  the  wound  was  dressed;  it 
was  found  in  good  condition ;  the  drainage  was 
removed ;  there  was  a  free  flow  of  cerebrospinal 
fluid. 

An  examination  by  Dr.  Mills  and  Dr.  Spiller 


117 

on  this  date  (October  15th)  resulted  as  fol- 
lows :  No  cutaneous  anaesthesia  was  present  on 
either  side ;  not  even  any  hypsesthesia  on  the  left. 
There  was  great  impairment  of  the  motor  divi- 
sion of  the  fifth  nerve,  the  masseter  and  pterygoid 
muscles  being  tested.  Complete  paralysis  in  the 
muscles  supplied  by  both  the  upper  and  lower 
branches  of  the  seventh  nerve  was  present.  She 
was  completely  deaf  in  the  left  ear.  Slight  pa- 
ralysis in  the  right  upper  extremity  was  noticed. 
Astereognosis  or  pseudoastereognosis  was  pres- 
ent in  the  right  hand.  Anaesthesia  for  both  touch 
and  pain  and  hypersesthesia  were  absent.  She 
had  had  no  pain  in  the  face  or  head  since  the 
operation,  and  had  required  no  anodynes. 

On  October  19th  the  wound  was  again  dressed 
and  the  stitches  were  removed ;  the  wound  was 
all  healed,  with  the  exception  of  one  angle;  a 
small  piece  of  gauze  was  inserted  for  drainage. 
The  patient's  general  condition  had  been  very 
good.     Her  pupils  were  now  normal. 

On  October  24th  the  surgical  condition  was 
entirely  satisfactory ;  the  wound  was  all  healed, 
with  the  exception  of  one  spot,  which  was  rapidly 
granulating.  The  patient's  general  condition  had 
rapidly  improved  since  last  noted.  She  was  re- 
gaining strength,  had  been  sitting  up  and  was 
quite  comfortable. 

On  October  29th  the  patient  was  discharged, 
the  surgical  condition  left  nothing  to  be  desired ; 
the  wound  was  completely  healed ;  there  was  no 
bulging  of  the  flap,  no  signs  of  inflammation  or 
oedema  of  the  scalp.     The  patient  had  not  had 


118 

any  pain  in  the  head  or  ears ;  the  only  discomfort 
had  been  some  irritation  of  the  conjunctiva  of  the 
left  eye,  which  was  probably  due  to  facial  palsy. 

This  patient  has  continued  under  the  observa- 
tion of  Dr.  Mills  and  Dr.  Frazier  from  the  time 
of  operation  until  that  of  writing  (December, 
1904).  From  the  time  of  operation  until  the 
present  she  has  not  had  any  pain  in  the  head,  al- 
though as  previously  stated,  the  pain  for  some 
time  before  the  operation  was  of  the  most  intense 
character.  In  other  respects,  her  general  con- 
dition has  been  good.  She  still,  however,  con- 
tinues to  be  partially  paralyzed  with  astereogno- 
sis  and  sensory  changes  on  the  right  side,  and 
still  has  paralysis  in  the  distribution  of  the  left 
seventh  nerve.  It  is  altogether  probable  that  a 
lesion  of  some  sort  is  still  present;  not  improb- 
ably she  has  more  than  one  lesion,  as  the  symp- 
toms point  both  to  the  pons  and  to  the  left  parietal 
lobe.  The  case  is  especially  interesting  as  show- 
ing how  in  some  cases  the  cerebellopontile  angle 
can  be  exposed  and  how  pain  and  other  symp- 
toms of  brain  tumor  are  sometimes  relieved  even 
when  full  success  is  not  obtained. 


THE  OCULAR  SYMPTOMS  OF  CEREBEL- 
LAR TUMOR. 

By  G.  E.  de  SCHWEINITZ,  M.  D, 

philadelphia, 

professor  of  ophthalmology,  university  of  pennsylvania. 

The  ocular  signs  of  cerebellar  growth  are  chiefly 
concerned  with  changes  in  the  fundus  oculi,  par- 
ticularly the  nerve  head,  and  with  anomalies  of  the 
external  ocular  muscles  and  the  movements  of  the 
eyeballs. 

I.       PAPILLITIS,    OR    CHOKED    DISC, 

(a)  Frequency. — In  order  to  ascertain  the  per- 
centage of  choked  disc  or  papillitis  in  cases  of  sus- 
pected intracranial  tumor,  Dr.  John  Weeks^  has 
collected  the  reports  of  677  brain  tumors,  and  finds 
that  those  which  involve  the  corpora  quadrigemina 
give  the  highest  percentage,  namely,  100;  next 
come  tumors  of  the  parietooccipital  region,  with  a 
percentage  of  87.8,  while  new  growths  of  the 
cerebellum  furnish  a  percentage  of  87.2.  In  his  list 
are  the  records  of  164  cases  of  cerebellar  tumor,  and 
only  21  times  was  optic  neuritis  absent.  In  an 
analysis  of  intracranial  tumors  with  respect  to  the 
existence  of  optic  neuritis  published  by  Edmunds 
and  Lawford,^  23  cases  of  neoplasm  of  the  cerebel- 

1  Transactions  of  the  Section  on  Ophthalmology  of  the  Ameri- 
can Medical  Association^  1899. 

2  Transactions  of  the  Ophthalmological  Society  of  the  United 
Kmgdom,  IV,  1884,  p.  82. 


120 

lum  are  reported,  and  in  20  of  them  optic  neuritis 
was  present,  being  absent  only  three  times.  It  is 
not  necessary  to  elaborate  these  statistics,  because 
the  fact  would  not  materially  be  altered  that  with 
the  exception  of  growths  of  the  corpora  quadri- 
gemina,  and  possibly  those  of  the  parietooccipital 
region,  cerebellar  tumors  yield  the  highest  percent- 
age of  papillitis,  or  so  called  choked  disc. 

(b)  Character  of  the  Neuritis  and  Nerve  Head 
Changes. — It  is  a  matter  of  common  observation 
that  optic  neuritis  develops  with  rapidity  in  cerebel- 
lar tumors,  indeed,  with  greater  rapidity  than  when 
they  are  elsewhere  situated.  In  the  words  of  Mr. 
Gunn,  intense  double  optic  neuritis,  with  great  en- 
gorgement of  the  papillae  and  with  surrounding 
retinal  change  coming  on  quickly,  suggests  a 
cerebellar  growth.  In  addition  to  a  papillitis  of  an 
intense  type,  that  is,  one  having  the  characteristics 
to  which  the  term  choked  disc  is  applied,  a  cerebel- 
lar growth  may  also  originate  a  more  moderate 
swelling  of  the  nerve  head,  somewhat  condensed 
in  appearance  and  comparatively  free  from  undue 
capillarity. 

It  is  not  possible  to  state  exactly  how  much  time 
must  be  consumed  before  the  optic  neuritis  of 
cerebellar  neoplasms  is  evident.  As  already  stated, 
the  development  is  usually  a  rapid  one,  and  the 
neuritis  may  appear  within  a  few  weeks,  or  even  a 


121 

few  days,  after  other  signs  of  involvement  of  this 
region  are  evident,  for  example,  intense  headache, 
vomiting,  and  vertigo.  Sometimes  longer  periods 
of  time  are  required  before  optic  neuritis  is  dis- 
covered. In  one  of  my  cases  with  other  well 
marked  signs  of  cerebellar  growth  there  was  no 
neuritis;  six  months  later  there  was  well  marked 
neuritis  in  one  eye  and  intense  papillitis  in  the  other. 

It  not  infrequently  happens  that  patients  come 
to  ophthalmoscopic  examination  after  the  papillitis 
has  already  subsided  and  a  postneuritic  atrophy  is 
present,  or  at  a  period  when  the  swelling  of  the 
disc  is  rapidly  disappearing  and  atrophy  beginning. 
Optic  nerve  atrophy,  without  signs  of  preexisting 
neuritis,  and  blindness,  unassociated  with  ophthal- 
moscopic lesions,  have  been  reported. 

It  is  well  known  that  the  papillitis  of  intracranial 
tumor  is  sometimes  unilateral  and  that  when  there 
is  a  one  sided  optic  neuritis,  or  a  marked  difference 
between  the  two  sides,  it  is  suggestive  of  the  fact 
that  the  cerebrum  is  the  seat  of  the  growth,  and,  on 
the  whole,  in  favor  of  the  tumor  being  on  the  same 
side  as  the  excess  of  neuritis.  Less  frequently 
unilateral  neuritis  occurs  in  cerebellar  tumor.  It 
was  noted  four  times  in  164  cases  of  the  Weeks 
collection.  Referring  to  this  point  Mr.  Gunn' 
writes  as  follows :  "  Taking  the  important  analysis 

3  Brain,  XXI,  1898,  p.  335. 


122 

of  6oi  cases  of  tumor  made  by  Dr.  J.  M.  Martin, 
and  paying  attention  to  the  relation  between  posi- 
tion, occurrence  of  optic  neuritis,  and  difference  of 
neuritis  on  the  two  sides,  I  find  that  there  was 
unilateral  neuritis  (or  excess)  in  lo  cases  of  frontal 
tumor,  and  in  8  of  these  it  occurred  on  the  same 
side  as  the  tumor.  In  four  cases  of  neuritis  differ- 
ence, in  cases  of  temperosphenoidal  growths,  the 
one  sided  excess  was  always  on  the  same  side.  Put- 
ting these  together,  we  have  the  unilateral  excess 
of  neuritis  on  the  same  side  as  the  tumor  in  12  out 
of  14.  The  unilateral  character  of  the  neuritis  was 
noted  in  10  cases  of  tumor  of  the  parietooccipital 
lobes  and  in  the  cerebellum.  In  5  of  these  it  was 
on  the  same  side  as  the  tumor  and  in  5  on  the  op- 
posite side." 

He  further  points  out  that  a  one  sided  difference 
of  neuritis  is  more  common  in  tumors  of  the  ce- 
rebral lobes  than  in  tumors  of  the  cerebellum.  In 
the  collection  before  referred  to  it  occurred  in  20 
per  cent,  of  all  of  the  cases  of  neuritis  with  tumors 
of  the  cerebrum,  and  in  only  about  3  per  cent.  c>f 
those  associated  with  tumor  of  the  cerebellum.  I 
have  not  seen  unilateral  neuritis  in  cerebellar 
growth,  although,  as  in  the  present  collection,  I 
have  noted  an  excess  of  neuritis  on  one  side  as 
compared  with  the  other. 

(c)  Retinal  Changes. — It  has  been  known  since 


123 

the  observations  of  von  Graefe,  Schmidt,  and 
Wegner,  more  than  thirty  years  ago,  that  appear- 
ances exactly  simulating  those  seen  in  retinitis  al- 
buminurica,  particularly  the  so  called  macular 
figure,  may  be  found  in  brain  tumor.  This  stellate 
macular  figure,  in  addition  to  the  swelling  of  the 
nerve  head,  has  been  noticed  with  particular  fre- 
quency in  cerebellar  tumors  and  has  been  the  sub- 
ject of  comment  especially  by  Dr.  James  Taylor 
and  Mr.  Marcus  Gunn.*  While  it  is  more  common 
to  find  this  stellate  figure  in  cerebellar  growths  than 
in  others  elsewhere  situated,  it  is  not  peculiar  to 
them,  and  Mr.  Gunn  himself  remarks  that  he  has 
seen  it  in  frontal  tumors.  One  of  the  best  marked 
examples  in  my  own  observation  occurred  in  a 
growth  which  was  certainly  in  the  cerebrum,  al- 
though its  location  was  not  proved  by  autopsy,  and 
another  excellent  example  appeared  in  a  subcortical 
growth  of  the  midregion  of  the  brain  which  had 
pressed  upon  the  optic  tracts  and  produced  hemian- 
opsia, and  which  was  removed  by  Dr.  Hearn  and 
Dr.  Da  Costa  in  the  Philadelphia  Hospital.  I  have 
also  seen  it  in  perfect  degree  in  several  cerebellar 
tumors,  one  particularly  in  the  Orthopaedic  Hos- 
pital and  another  under  the  care  of  Dr.  Mills  and 
Dr.  Frazier  in  the  University  Hospital,  a  full  eye 

*  Transactions  of  the  Eighth  International  Medical  Congress, 

Edinburgh,  1894. 


124 

examination  of  which  is  recorded  in  the  present 
paper. 

Other  retinal  changes  not  significant  of  cerebel- 
lar tumor  may  also  appear,  for  example,  postneuritic 
atrophy,  perivasculitis,  areas  of  atrophy  marking 
the  position  of  former  haemorrhages,  exudations 
and  sclerotic  alterations  in  the  retinal  vessels,  if 
the  patient  has  also  been  the  subject  of  general 
arteriosclerosis. 

(d)  Visual  Acuity. — It  is  well  known  that  optic 
neuritis  caused  by  intracranial  growth  is  perfectly 
compatible  with  good  visual  acuity,  but  if  the 
growth  is  situated  in  the  cerebellum  there  is  apt  to 
be  early  great  disturbance  of  vision,  rapidly  pro- 
ceeding to  blindness.  Edmunds  and  Lawford  re- 
ferring to  the  frequency  of  blindness  under  these 
circumstances,  compare  it  with  the  optic  neuritis 
which  occurs  in  tumors  of  the  basal  ganglia,  which 
in  their  table  yield  next  to  cerebellar  growths  the 
highest  percentage  of  optic  neuritis,  but  in  only  five 
of  the  twenty  cases  was  blindness  present,  as  against 
nine  which  progressed  to  blindness  in  twenty-three 
cases  of  cerebellar  tumor.  Moreover,  of  the  twenty 
cases  with  optic  neuritis,  seven  were  blind  on  ad- 
mission to  the  hospital  and  two  others  became  blind 
before  death.  They  suggest  that  as  cerebellar  tu- 
mors are  not  so  rapidly  fatal  as  basal  tumors,  time 


125 

is  allowed  for  the  neuritis  to  pass  on  to  atrophy 
and  to  blindness. 

Dercum^  in  1893  tentatively  advanced  the  follow- 
ing explanation  of  early  blindness  in  cerebellar 
growths:  "The  proximity  of  the  quadrigeminal 
bodies  naturally  suggests  itself  as  in  some  way  ex- 
plaining this  blindness.  A  consideration  of  anatomy 
will  show  that  if  a  growth  be  situated  in  the  vermi- 
form process,  especially  anteriorly,  and  that  if  this 
growth  continues  to  enlarge,  it  will  sooner  or  later 
press  upon  the  superior  cerebellar  peduncles,  and 
very  probably  upon  the  quadrigeminal  bodies  them- 
selves. Now  if  we  recall  the  relation  which  the 
fibres  of  the  optic  tracts  bear  to  the  primary  optic 
centres  one  can  readily  understand  how,  if  pressure 
or  irritation  occurs  at  this  point,  a  neuritis  would 
be  the  consequence.  Further,  the  irritation  being 
direct,  one  can,  perhaps,  understand  why  the  neu- 
ritis should  be  of  a  high  grade;  and  finally,  also, 
why  this  neuritis  should  be  associated,  sooner  or 
later,  with  total  blindness."  Recognizing,  however, 
that  this  hypothesis,  especially  in  so  far  as  it  refers 
to  the  development  of  the  neuritis,  is  unsatisfactory, 
Dercum  has  abandoned  it. 

Oppenheim®  thinks  that  upon  the  hydrocephalus 
which  almost  always  accompanies  in  considerable 

"  Journal  of  Nervous  and  Mental  Disease,  18,  1893.  p.  683. 
*  Die  Oeschwiilste  des  Gehirns,  by  Prof.  Dr.  H.  Oppenheim, 
Wien,  1896,  p.   144. 


126 

degree  tumors  of  the  cerebellum,  depends  the  de- 
cided choked  disc  and  its  prompt  arrival,  as  well 
as  the  early  amblyopia,  to  be  followed  later  by 
amaurosis.  According  to  him,  the  rapid,  sometimes 
sudden,  appearance  of  amaurosis  is  due  to  a  com- 
pression which  injures  the  chiasm  and  which  is 
caused  by  a  bulging  forward  of  the  floor  of  the 
third  ventricle.  A  similar  explanation  is  applicable 
to  those  cases  of  amblyopia  and  blindness  without 
eyeground  changes  which  have  been  observed  by 
Curschmann,  Gerhardt,  and  others.  The  optic 
nerve  atrophy,  which  is  sometimes  noted  in  cerebel- 
lar disease  without  evidence  of  much  preexisting 
neuritis,  Oppenheim  also  attributes  to  pressure  upon 
the  chiasm. 

It  would  seem,  therefore,  that  the  blindness  may 
be  explained  in  part  by  direct  pressure  from  hydro- 
cephalus, and  in  part  by  the  compression  of  the 
optic  nerve  fibres  and  their  subsequent  atrophy 
owing  to  the  high  grade  of  engorgement  oedema,  or 
to  an  actual  neuritis.  The  relation  which  the  de- 
struction of  the  ganglion  cells  of  the  retina  bears 
to  this  blindness  requires  further  study,  and  it  may 
be  that  their  disintegration  will  account  for  some 
of  the  cases  of  early  and  even  sudden  blindness  in 
cerebellar  tumor  associated  with  papillitis  of  marked 
degree. 

(e)  Effect  of  Operation  on  Papillitis. — In  so  far 


127 

as  the  patholog-ical  examinations  of  cerebellar  optic 
neuritis  are  concerned,  they  do  not  differ  from  those 
which  have  been  made  in  the  optic  neuritis  of  other 
intracranial  growths,  and  it  is  not  germane  to  the 
present  topic  to  discuss  this  subject  concerning 
which  there  is  still  much  difference  of  opinion.  In 
general  terms,  microscopical  examination  would 
seem  to  indicate  that  in  a  certain  number  of  cases 
of  papillitis,  be  they  of  cerebral  or  cerebellar 
origin,  there  is  a  true  engorgement  cedema,  and 
that  the  evidence  of  inflammation,  in  any  decided 
degree  at  least,  is  lacking,  while  in  other  cases  the 
inflammatory  signs  are  marked.  When  the  en- 
gorgement oedema  is  the  marked  feature,  the  oph- 
thalmoscope reveals  the  typical  picture  of  choked 
disc.  When,  on  the  other  hand,  the  inflammatory 
condition  predominates,  the  elevation  of  the  disc 
may  be  less  marked  and  the  process  may  extend  to 
the  surrounding  retina.  In  other  words,  there  is  an 
iniiammatory  optic  neuritis.  Now,  if  one  sees  the 
case  during  the  period  of  engorgement  oedema,  be- 
fore inflammatory  exudates  are  present,  naturally 
it  is  desirable  to  reduce  the  swelling  of  the  nerve 
head.  Horsley,  Bruns,  Erb,  James  Taylor,  and 
many  others  have  called  attention  to  the  fact  that 
there  may  be  a  subsidence  of  the  optic  neuritis  after 
operation  undertaken  with  a  view  to  the  removal 
of  an  intracranial  tumor,  even  when  the  tumor  was 


138 

not  removed,  and  Taylor  has  recorded  a  number 
of  examples  of  this  character.  Certainly,  as  Hors- 
ley  points  out,  removal  of  pressure  is  one  of  the 
factors  in  the  reduction  of  optic  neuritis  in  intra- 
cranial tumors,  and  as  Hill  Grififith  has  said,  should 
there  be  recovery  after  blindness  with  optic  neuritis 
by  trephining,  the  indications  are  that  the  optic 
nerv^e  condition  was  produced  by  pressure. 

Saenger'''  reports  prompt  subsidence  of  double 
sided  choked  disc  after  palliative  trephining  for 
cerebellar  growth  and  advises  this  operative  pro- 
cedure in  tumors  which  cannot  be  removed  in  order 
to  relieve  pressure  symptoms  and  especially  to  avoid 
impending  blindness.  In  seven  cases  of  double 
choked  disc  he  has  noted  a  disappearance  of  this 
condition  after  such  trephining.  In  two  of  the  pa- 
tients described  by  Dr.  Mills  in  the  present  paper 
and  trephined  by  Dr.  Frazier,  with  removal  of  the 
growth,  there  was  decided  and  comparatively 
prompt  subsidence  of  the  choked  disc.  In  one  of 
these  blindness  occurred,  but  the  patient  was  prac- 
tically blind  when  she  was  trephined.  In  the  other 
the  visual  acuity  before  the  operation,  which  was 
good,  that  is,  two  thirds  of  normal,  has  been  main- 
tained until  the  present  time  and  the  neuritis  has 
partly  subsided.* 

'' Miinch.  med.  Wochenschr.,  XLVIII,  1901,  p.  2. 

^  Since  this  sentence  was  written  the  patient  has  been  seen, 
and  the  vision  has  begun  to  fail  and  a  partial  ophthalmoplegia 
has  developed ;  evidently  there  has  been  recurrence. 


129 

If  it  be  true,  as  Merz  declares,  that  increased 
intracranial  tension  alone  is  sufficient  to  produce 
choked  disc,  provided  this  tension  shall  be  main- 
tained uninterruptedly  for  a  certain  time,  and  if 
further  it  is  true,  as  would  seem  from  reported 
cases,  that  there  is  reduction  of  such  tension  by 
trephining,  even  where  the  tumor  is  not  removed, 
then  certainly  Saenger's  advice  that  such  palliative 
trephining  should  be  performed  early,  especially  in 
the  choked  disc  of  cerebellar  tumor,  which  is 
almost  sure  to  produce  blindness,  is  sound  and 
should  be  followed. 

II. — ANOMALIES    OF    THE    OCULAR    MUSCLES    AND    OF 
THE    MOVEMENTS    OF    THE    EYEBALLS. 

Owing  to  the  anatomical  relations  of  the  cere- 
bellum, tumor  formation  in  this  region  may  bring 
about  involvement  of  certain  of  the  cranial  nerves, 
particularly  the  facial  and  the  auditory.  In  so  far 
as  the  eye  muscle  nerves  are  concerned,  the  abducens 
is  by  far  the  most  frequently  ajffected,  and  conver- 
gent paralytic  strabismus  with  involvement  of  one 
or  both  abducens  nerves  is  not  an  unusual  symptom 
in  cerebellar  growth.  In  a  case  reported  by  Saenger 
with  gliosarcoma  of  the  left  cerebellar  hemisphere, 
there  was  double  abducens  paralysis  with  marked 
thinning  of  the  nerves,  and  in  a  similar  growth  re- 
corded by  Sander  the  abducens  paralysis  was  ex- 


130 

plained  by  finding  a  lesion  in  its  nucleus.  Wernicke 
states  that  sixth  nerve  paralysis  is  most  apt  to  be 
present  as  a  distant  symptom  when  the  tumor  is 
situated  in  the  cerebellum.  In  this  respect  the  sixth 
differs  from  the  third  nerve,  v^^hich,  as  Swanzy  has 
well  shown,  is  more  likely  to  give  distant  symptoms 
with  a  lesion  of  the  cerebral  hemisphere. 

In  one  case  recorded  by  Dr.  Mills  in  the  present 
paper  where  the  cerebellum  and  the  pons  oblongata 
were  exposed  and  a  cyst  was  discharged,  there  was 
paralysis  of  the  branch  supplying  the  left  levator 
palpebrae  and  the  left  inferior  rectus.  According 
to  Oppenheim  ptosis  and  reflex  immobility  of  the 
pupil  without  loss  of  sight  and  paresis  of  accom- 
modation have  been  observed,  and  he  quotes 
Mackenzie,  Bruns,  and  other  authors  as  having 
observed  a  more  or  less  complete  ophthalmoplegia.^ 
A  rare  ocular  muscle  palsy  is  one  that  affects  the 
superior  oblique,  that  is  to  say,  the  trochlearis  is 
involved.  Referring  to  the  setiology  of  these  con- 
ditions, Oppenheim  remarks  that  the  paralyses  must 
depend  upon  a  lesion  of  the  nerve  trunks  them- 
selves, or  UDon  pressure  exerted  on  the  region 
of  their  nuclei.  When  ophthalmoplegia  is  evident, 
it  may  be  explained  by  an  involvement  of  the  cor- 
pora quadrigemina. 

» In  one  case  at  present  under  my  observation  there  is  paraly- 
sis of  all  external  ocular  muscles  except  the  inferior  recti,  which 
are  beginning  to  be  involved,  and  the  superior  obliques. 


131 

Bruns/°  referring  to  the  difficulty  of  telling  on 
which  side  of  the  cerebellum  a  tumor  has  its  sit- 
uation, speaks  of  the  help  obtained  in  this  respect 
when  certain  nerves  are  paralyzed,  for  example, 
the  trifacial,  the  facial,  and  the  auditory,  and  refers 
as  a  frequent  symptom  to  the  presence  of  associated 
paralyses  of  ocular  movements  which  then  appear 
toward  the  side  of  the  tumor.  So  frequent  are  these 
paralyses  that  in  large  tumors  of  the  cerebellum 
Bruns  considers  them  to  be  constant. 

Oppenheim,  discussing  the  same  subject,  remarks 
that  this  symptom,  that  is,  a  paralysis  of  associated 
parallel  movements  of  the  eyes  toward  the  side  of 
the  tumor  with  deviation  of  the  eyes  toward  the 
opposite  side,  depends  upon  a  one  sided  compres- 
sion of  the  pons.  It  is,  therefore,  the  rule  that  the 
eyes  of  these  patients  cannot  be  moved  toward  the 
side  of  the  tumor.  He  warns,  however,  that  the 
symptom  cannot  be  absolutely  trusted,  inasmuch  as 
in  two  cases  under  his  own  observation  there  was 
paralysis  of  associated  parallel  movements  toward 
one  side  when  the  vermiform  process  was  the  part 
involved  in  the  tumor  formation. 

According  to  Gowers,  an  unsymmetrical  position 
of  the  eyes,  one  directed  upward  and  inward  and 
the  other  one  downward  and  outward,  has  been  ob- 

"  Neurologisches  CentraVbl.,  18,  1899,  p.  519. 


132 

served  as  a  rare  symptom  of  tumor  of  the  middle 
peduncle  of  the  cerebellum. 

Nystagmus  is  almost  always  present  in  cerebellar 
tumors.  It  may  be  rotary  or  vertical,  but  is  most 
frequently  lateral.  Sometimes  it  is  not  observable 
when  the  gaze  is  directed  forward  but  develops  at 
once  in  right  or  left  Isevoversion. 

It  would  seem  also  that  in  a  certain  number  of 
cases  the  nystagmus  is  evident  only  when  the  eyes 
are  turned  toward  the  side  on  which  the  tumor  is 
situated,  and,  indeed,  that  such  nystagmus  may  be 
the  sole  ocular  sign  of  the  cerebellar  growth.  For 
example,  Pineles^^  observed  in  a  patient  with  normal 
eyegrounds  nystagmus  only  when  the  eyes  were 
directed  to  the  left.  Post  mortem  examination  re- 
vealed a  walnut  sized  tubercle  in  the  left  cerebellar 
hemisphere,  the  middle  of  the  lobus  quadrangularis 
being  also  involved.  This  development  of  nystag- 
mus when  the  eyes  are  rotated  toward  the  side  of 
the  tumor  has  been  commented  upon  by  a  number 
of  observers.  It  has  been  noticed  by  Mills,  Spiller, 
and  by  myself  in  several  cases  which  we  have  exam- 
ined together.  In  place  of  a  true  nystagmus,  a 
nystagmoid  movement  is  often  observable  when  the 
eyes  are  turned  from  side  to  side,  particularly  if 
there  is  an  associated  paralysis  of  the  external  rec- 
tus.    There  is  no  doubt  that  nystagmus  may  be 

"  Arbeiten  aus  Oiersteiner's  Laioratorium,  Heft  4,  1899. 


133 

regarded  as  a  direct  cerebellar  symptom.  It  has 
also  been  referred,  according  to  Amheim  who 
quotes  Russell  in  this  respect,  to  a  paralysis  of  the 
ocular  muscles. 

That  double  optic  neuritis,  internal  strabismus, 
and  nystagmoid  movements  on  looking  both  to  the 
right  and  to  the  left,  must  not,  however,  be  regarded 
as  characteristic  or  pathognomonic  of  cerebellar 
tumor,  is  evident  from  a  case  recorded  by  Bram- 
well,^^  in  which  these  symptoms  were  present  and 
the  lesion  consisted  of  a  dilatation  of  the  ventricles, 
especially  of  the  fourth  ventricle,  the  result  of  a 
previous  meningitis  and  an  obliteration  of  the  fora- 
men of  Magendie.  The  oscillation  of  the  globes  in 
blindness  from  cerebellar  tumor  must  not  be  con- 
fused with  true  nystagmus. 

There  is  nothing  characteristic  in  the  pupil  reac- 
tions in  disease  of  this  region.  If  there  is  blindness 
and  loss  of  light  perception,  there  is  naturally  loss 
of  the  light  reflex,  while,  if  light  perception  remains, 
this  reflex  is  preserved. 

So,  also,  the  field  of  vision  furnishes  no  charac- 
teristic changes.  It  may  be  perfectly  intact  or  con- 
centrically or  irregularly  contracted,  according  to 
the  degree  of  atrophy  existing  in  the  optic  nerves. 
In  some  cases  there  seems  to  have  been  hemian- 
opsia,   but    probably    only    a    contraction    of    the 

"Brain,  XXII,  1899,  p.  68. 


134 

visual  field  resembling  this  phencmenon  due  to 
atrophy  in  the  optic  nerve,  or  alteration  in  the  gang- 
lion cells  of  the  retina.  It  is  of  course  conceivable 
that  hemianopsia  could  occur  as  an  associated 
symptom  if  with  the  cerebellar  growth  there  were 
other  lesions  which  pressed  upon  some  portion  of 
the  optic  pathway. 


THE     PATHOLOGY     OF     CEREBELLAR 
TUMORS.* 

By  T.  H.  WEISENBURG,  M.  D., 

philadelphia, 

instructor  in  neurology  and   neuropathology,  univer- 
sity of  pennsylvania;  assistant  neurologist  to 
the  philadelphia  general  hospital. 

It  is  not  the  purpose  of  this  paper  to  consider 
minutely  the  histology  of  cerebellar  growths,  as 
this  information  can  be  obtained  in  any  textbook 
on  neurology.  The  pathological  aspects  of  the 
various  conditions  which  give  the  symptoms  of 
cerebellar  tumor  will  be  considered,  especially  in 
a  surgical  sense. 

It  is  difficult  to  make  a  satisfactory  classifica- 
tion of  such  a  subject,  but  the  following  plan 
will  be  adopted: 

1.  The  ordinary  tumors  in  their  order  of  frequency,  as 
glioma,  tuberculoma,  cysts,  and  so  forth,  of  the  cerebellum 
itself. 

2.  Growths  of  the  surrounding  regions  giving  cerebellar 
symptoms,  as  of  the  fourth  ventricle,  medulla  oblongata, 
pons,  and  corpora  quadrigemina. 

3.  Growths  in  parts  besides  those  mentioned,  giving  cere- 
bellar symptoms. 

4.  Abscess  of  the  cerebellum. 

*  From  the  Neuropathological  Laboratory  of  the  University 
of  Penrsylvania. 


136 

5-  Internal  hydrocephalus,  with  symptoms  of  cerebellar 
tumor. 

6.  Cerebellar  symptoms  without  any  lesions. 

7.  Lesions  of  the  cerebellum  without  any  symptoms. 

Excellent  statistical  studies  of  the  frequency 
of  the  cerebellar  and  other  cranial  growths  have 
been  made,  and  without  the  desire  to  add  to  the 
already  voluminous  literature  on  the  subject,  it 
has  been  thought  advisable  to  give  a  brief  report 
of  the  brain  tumors  now  in  the  neuropathological 
laboratory  of  the  University  of  Pennsylvania, 
which  is  under  the  direction  of  Professor  Wil- 
liam G.  Spiller.  This  collection  has  largely  been 
accumulated  in  the  last  three  or  four  years,  and 
is  from  the  services  of  Dr.  Mills  and  Dr.  Spil- 
ler, although  in  a  number  of  instances  specimens 
have  been  obtained  from  other  sources. 

Tumors  of  the  cerebral  cortex  and  subcortex 27 

Cerebellar  tumors 9 

Tumors  of  the  brain  stem 9 

Tumors  implicating  both  brain  and  cord 4 

Tumors  of  the  cerebral  cortex  and  subcortex : 

Sarcoma    13 

Fibrosarcoma    2 

Endothelioma 4 

Glioma    3 

Gumma    2 

Carcinoma 1 

Adenoma 1 

Tuberculoma    X 

Cerebellar  tumors : 

Glioma 5 

Sarcoma 1 

Fibroma   (in  the  cerebellopontile  angle) 3 


137 


Tumors  of  the  brain  stem  : 

Pons :    Tuberculoma    2 

Glioma 1 

On  the  pons  and  medulla  oblongata :  Sarcoma 1 

On  the  medulla  oblongata  :  Chondrosarcoma 1 

Within  the  fourth  ventricle  :  Sarcoma 2 

On  the  corpora  quadrigemina  :  Fibroma 1 

Within  the  corpora  quadrigemina :  Glioma 1 

Tumors  of  the  brain  and  cord :  General  sarcomatosis,  with 

large  tumors,  especially  in  the  cerebellopontile  angle 4 

Sections  of  at  least  seven  other  brain  tumors 
were  not  considered,  because  definite  knowledge 
of  the  location  of  the  growths  was  lacking. 

According  to  statistics  tumors  of  the  cerebel- 
lum are  less  frequent  than  of  the  cerebrum. 
Schuster,  in  a  statistical  table  of  some  thousand 
cases  of  brain  tumor,  found  21.6  per  cent,  to  be 
cerebellar.  When  the  relative  size  of  the  cere- 
bellum and  the  cerebrum  is  considered,  it  is  prob- 
able that  new  growths  are  more  frequent  in  the 
former. 

Tuberculous  growths  are  more  common  in  per- 
sons below  the  age  of  twenty  years,  while  gli- 
oma, sarcoma,  and  cysts  of  various  kinds  are 
more  frequent  in  the  adult.  The  frequency  of 
fibroma,  especially  of  the  acoustic  nerve,  is  be- 
coming better  recognized.  Syphilitic  tumors  of 
the  cerebellum  are  rare.  Of  the  other  forms  of 
new  growths,  as  carcinoma,  lipoma,  angeioma, 
psammoma,  and  dermoid  cysts,  there  are  very 
few  instances  in  the  literature. 


138 

The  lateral  lobes  of  the  cerebellum  possibly 
because  of  their  greater  size,  seem  to  be  more 
frequently  the  seat  of  tumors  than  the  middle 
lobe,  although  writers  differ  upon  this  point.  Tu- 
mors within  the  middle  cerebellar  peduncle  are 
rarely  found,  although  a  tumor  within  this 
peduncle  is  present  in  one  of  the  specimens  in 
the  laboratory.  Growths  in  the  anterior  and 
posterior  cerebellar  peduncles  are  also  uncom- 
mon. The  angle  formed  by  the  cerebellum,  me- 
dulla oblongata,  and  pons  is  a  favorite  seat  for 
new  growths,  these  tumors  growing  either  from 
within  or  upon  the  acoustic,  facial,  or  trigeminus 
nerves,  and  frequently  are  fibromata. 

Tuberculoma. — In  152  tuberculous  brain  tumors 
collected  by  Allen  Starr,  occurring  in  childhood, 
47  were  in  the  cerebellum.  In  the  adult  they  are 
found  with  equal  frequency  in  this  region  and 
in  the  pons  and  the  cerebral  cortex.  They  are 
nearly  always  multiple,  and  secondary  to  a  tuber- 
culous process  elsewhere  in  the  body.  A  tend- 
ency to  symmetrical  arrangement  is  also  ob- 
served (Oppenheim).  Their  size  varies  from  a 
small  nodule  to  a  large  fist.  Macroscopically,  it 
is  hard  to  distinguish  a  tuberculoma  from  a  syph- 
iloma. Both  have  poor  blood  supply  and  a  tend- 
ency to  caseate,  the  tuberculous  growth  to  pus 
formation.    Again,  both  have  a  tendency  to  grow 


139 

from  the  meninges,  although  the  tuberculous 
growths  are  found  in  the  substance  of  the  brain, 
and  may  have  granulation  areas  and  miliary  tu- 
bercles about  their  border.  It  must  be  recalled, 
however,  that  syphilitic  tumors  of  the  cerebel- 
lum are  rare. 

The  growth  of  a  tubercle  may  be  either  rapid 
or  slow.  Tuberculous  tumors  may  give  no  clin- 
ical symptoms.  This  has  been  explained  by  the 
slowness  of  the  growth,  the  cerebellum  gradually 
accommodating  itself  to  increased  pressure. 
Very  recently,  however,  Raubitschek  was  able  to 
demonstrate  the  persistence  of  the  axis  cylinders 
in  tuberculous  growths  by  Bielchowsky's  meth- 
od. This,  as  in  multiple  sclerosis,  explains  the 
persistence  of  function.  Surgically,  it  is  not  ad- 
visable to  operate  upon  these  growths,  as  they  are 
multiple  and  cannot  be  removed. 

Glioma. — The  cerebellum  is  a  favorite  seat  for 
glioma.  Five  of  our  cerebellar  growths  were  of 
such  nature.  Gliomata  are  almost  always  pri- 
mary and  single,  although  metastasis  has  been 
noted.  The  tumor  may  be  as  small  as  a  cherry 
or  as  large  as  a  hen's  egg;  it  always  grows  from 
the  brain  substance  itself,  and  is  of  slow  growth. 
It  is  not  sharply  defined,  but  infiltrates  into  the 
brain  substance,  and  it  is  difficult  to  tell  it  from 
normal  brain   tissue,   although  sometimes   there 


140 

is  an  increased  consistence  to  pressure  and  there 
may  be  a  slight  swelling.  The  border  zone  of 
the  tumor  may  present  an  increased  number  of 
blood  vessels  and  there  may  be  islets  of  new  tis- 
sue. 

Gliomata  may  be  hard  or  soft,  depending  upon 
the  excess  of  cells  or  fibrils,  and  have  a  yellowish 
white  or  reddish  appearance.  Cystic  formation 
is  very  common,  some  authors  believing  that  the 
whole  tumor  mass  may  disappear,  leaving  noth- 
ing but  a  cyst  wall,  and  that  it  is  necessary  to 
examine  microscopically  the  capsule  to  deter- 
mine the  gliomatous  origin.  Cysts  form  in  the 
neighborhood  of  these  tumors,  and  the  surgeon 
may  tap  one  of  these  cystic  formations,  believ- 
ing it  to  be  the  only  lesion  present.  It  is  wise, 
as  Oppenheim  has  pointed  out,  to  remove  always 
a  part  of  the  cyst  wall  for  microscopic  examina- 
tion. The  fluid  inside  of  these  cysts  may  be 
whitish  or  bloody  in  character.  Fatty,  hsemor- 
rhagic,  and  myxomatous  changes  occur  in  glioma- 
tous tumors. 

Microscopically,  it  is  difficult  to  distinguish  a 
glioma  from  a  sarcoma  unless  a  differential  stain 
has  been  employed.  There  is  some  doubt  as  to 
the  simultaneous  occurrence  of  glioma  and  sar- 
coma, the  so  called  gliosarcoma,  some  authors  be- 
lieving this  to  be  impossible,  as  the  former  is  of 


141 

ectodermal  and  the  latter  of  mesodermal  origin. 
Others  believe  that  by  metaplastic  processes  a 
sarcomatous  structure  may  develop  from  neuro- 
gliar  tissue.  According  to  certain  pathologists, 
a  gliosarcoma  should  only  be  diagnosticated 
where  a  sarcomatous,  perivascular  cellular  mass 
is  found  within  a  glioma. 

It  can  readily  be  understood  from  the  slow 
growth  and  from  its  infiltrating  character  why 
clinical  symptoms  of  brain  tumor  do  not  always 
appear,  or  not  until  late  in  the  disease.  Sur- 
gically, it  is  difficult  or  even  impossible  to  re- 
move completely  such  a  tumor.  Sections  made  from 
the  specimens  removed  at  the  operation  in  Cases 
I  and  II  of  Dr.  Mills  and  Dr.  Frazier  showed  a 
glioma  in  each  instance. 

Sarcoma. — This  form  of  brain  tumor  is  about 
as  common  as  the  glioma,  although  in  our  ex- 
perience sarcomata  have  been  more  frequently 
found.  The  growth  may  be  small,  flat,  or  nodu- 
lar, or  may  be  of  large  size.  It  is  primary  and 
usually  solitary.  Sarcoma  always  grows  from 
the  meninges,  periosteum,  or  cranial  bones,  or 
from  the  pial  covering  of  the  blood  vessels.  It 
never  grows  from  the  brain  substance,  and  there- 
fore, unlike  the  glioma,  it  often  compresses  the 
brain  tissue  and  may  be  distinct  from  it,  although 
not  infrequently  it  infiltrates   the  latter.      Even 


142 

when  growing  within  the  brain  a  distinct  mar- 
gin sometimes  may  be  found,  due  to  the  softened 
area  surrounding  it.  It  is  usually  harder  in  con- 
sistency than  a  glioma,  and  is  slow  in  its  growth. 

The  tumor  may  soften  or  caseate.  Myxoma- 
tous, hemorrhagic,  and  cystic  changes  are  not 
uncommon.  Cystic  changes  are  especially  com- 
mon in  the  cerebellum,  not  only  in  sarcomata, 
but  also  in  gliomata.  In  one  of  Dr.  Spiller's  cases 
small  sarcomatous  masses  were  found  in  the 
walls  of  a  cyst.  If  the  fibrous  tissue  is  very 
marked  we  have  a  fibrosarcoma. 

Sarcoma  may  manifest  itself  as  a  diffuse  mul- 
tiple sarcomatosis.  In  an  excellent  article  Spil- 
ler  recorded  two  such  cases  and  called  attention 
to  the  rarity  of  this  disease.  He  quotes  Schle- 
singer,  who  subdivided  the  tumors  under  the 
head  of  multiple  sarcomatosis  into 

(a)  Diseases  of  the  nervous  substance  and 
meninges, 

(b)  Multiple  sarcomatosis  of  the  membranes 
without  sarcoma  of  the  brain  or  cord,  when  it  is 
(i)  in  the  form  of  multiple  small  tumors,  or  (2) 
a  diffuse  sarcomatous  infiltration  of  the  mem- 
branes. 

Of  twenty  cases  recorded  by  Schlesinger,  four- 
teen implicated  the  brain  and  cord  or  their  mem- 
branes.    "  In  nine  of  these  fourteen  cases  cere- 


Pig.  1. — Sarcoma  in  left  cerebellopontile  angle.     Small  tumor  in 
right  cerebellopontile  angle  does  not  show  in  photograph. 


145 


bellar  tumor  was  found,  and  in  three  the  medulla 
oblongata  was  affected.  It  appears,  therefore, 
that  when  the  brain  or  its  membranes  are  im- 
plicated in  sarcomatosis,  usually  the  structures 
of  the  posterior  cranial  fossa  are  affected,  and 
that  in  about  two  thirds  of  the  cases  a  tumor  of 
the  cerebellum  is  found." 

In  Spiller's  first  case  a  large  sarcoma  was 
found  in  the  left  cerebellar  lobe,  and  in  his  sec- 
ond case  a  tumor  was  found  in  each  cerebello- 
pontile  angle,  the  larger  one  being  on  the  left 
side,  as  shown  in  Fig.  i.  Tumors  were  also 
found  in  this  case  in  the  Gasserian  ganglia,  pitui- 
tary body,  floor  of  the  fourth  ventricle,  right  in- 
ternal auditory  meatus,  and  right  jugular  fora- 
men, and  numerous  small  tumors  were  found  in 
the  pia  of  the  spinal  cord. 

It  may  be  impossible,  as  in  Spiller's  second 
case,  to  make  a  correct  diagnosis  in  sarcomatosis 
of  the  brain  and  of  the  pial  covering.  Extensive 
alteration  may  cause  few  clinical  symptoms,  be- 
cause the  soft  tumor  masses  grow  in  the  pia  and 
about  the  cranial  nerves  and  spinal  roots,  and 
may  produce  little  or  no  compression  or  destruc- 
tion of  the  nervous  tissue.  Spiller  insists  upon 
the  importance  of  remembering  this  fact,  for 
when  evidences  of  sarcomatosis  are  found,  the 
case  is  an  inoperative  one. 


146 

Occasionally  th^  process  may  invade  the  brain 
substance,  while  the  nerve  roots  may  escape.  It 
is,  according  to  Spiller,  because  of  this  escape  of 
the  nervous  tissue  in  many  cases  that  a  correct 
diagnosis  of  the  extent  of  the  process  may  be 
impossible. 

The  infiltration  of  the  pia  may  resemble  that 
caused  by  syphilis  or  tuberculosis.  Again,  as  in 
Nonne's  case,  the  macroscopical  examination 
may  be  normal. 

Sarcomatous  tumors,  according  to  Westphal, 
occur  more  often  in  the  young.  When  tumors 
occur  in  the  posterior  cranial  fossa  they  have  a 
predilection  for  the  cerebellopontile  angle  and 
the  internal  auditory  meatus. 

Isolated  sarcomata  whether  of  the  cere- 
bellum or  of  any  other  region  of  the  brain  are, 
next  to  fibromata,  among  the  most  favorable 
forms  of  tumor  for  surgical  removal.  Of  course 
the  question  of  multiple  sarcomatosis  must  al- 
ways be  carefully  considered  when  deciding  upon 
operation.  With  regard  to  surgical  procedure 
the  hard  non-infiltrating  sarcomata  are  the  most 
favorable.  Experience  shows,  however,  that  a 
sarcoma  which  appears  to  be  infiltrating  when 
the  brain  and  tumor  mass  are  first  exposed,  is 
often  separable  from  the  brain  substance. 

Syphilitic  Growths. — Gummata  are  rarely  found 


147 

post  mortem,  although  they  are  possibly  the  most 
common  cranial  growths.  They  are  especially 
rare  in  the  cerebellum.  The  resemblance  be- 
tween this  growth  and  tuberculoma  has  already 
been  discussed.  In  a  recent  article  Mills  recorded 
two  cases  in  which  the  diagnosis  of  a  tumor  in 
the  cerebellopontile  angle  was  made.  At  the 
necropsy  no  tumors  were  apparent,  but  micro- 
scopically in  the  first  case  a  diffuse  syphilitic 
basal  meningitis  was  found  and  in  his  second 
case  besides  a  meningitis  at  the  base,  there  were 
numerous  areas  of  softening  throughout  the 
brain,  extending  from  the  gray  into  the  white 
matter.  These  areas  of  softening  were  yellow- 
ish red  in  color,  soft  in  consistence,  and  were 
well  defined  from  the  surrounding  brain  sub- 
stance. Microscopically,  there  was  an  intense 
round  cell  infiltration  about  the  blood  vessels 
and  within  the  tissues. 

These  cases  illustrate  well  the  nature  of  syph- 
ilitic new  growths.  It  is  well  known  that  a  syph- 
ilitic basal  meningitis,  or  meningoencephalitis, 
may  attack  any  cranial  nerve  or  combination  of 
cranial  nerves,  but  according  to  Mills  they  show 
a  predilection  in  favor  of  the  nerves  from  the  sec- 
ond to  the  seventh  inclusive,  of  these  the  fifth 
perhaps  most  frequently  escaping. 

Syphilitic  growths  are  rapid  in  development. 


148 

but  it  must  be  remembered  that  the  various  path- 
ological conditions  which  lead  on  to  these 
growths  have  been  long  present. 

Fibromata. — These  tumors  are  rare,  but  they 
are  relatively  more  frequent  in  the  cerebellum 
than  in  the  cerebrum,  and  especially  in  the  cere- 
bellopontile  angle.  This  has  been  better  recog- 
nized within  the  last  few  years,  because  of  the 
relatively  successful  surgical  removal  of  tumors 
growing  in  this  area. 

A  fibroma  invading  the  cerebellopontile  an- 
gle may  be  only  a  part  of  a  general  neurofibroma- 
tosis ;  this,  however,  is  rare,  or,  what  is  more 
common,  it  may  be  the  only  expression  of  this 
process,  a  central  neurofibromatosis.  The  growth 
is  slow,  and  generally  is  unilateral,  although  in 
rare  instances  it  may  be  present  on  both  sides. 
Henneberg  and  Koch  pointed  out  that  these  tu- 
mors are  more  often  found  on  the  left  side  in  the 
ratio  of  three  to  two.  In  the  cases  reported  by 
Dr.  Mills,  the  pathological  reports  of  which  are 
here  given,  the  neoplasms  were  on  the  left  side. 
In  an  examination  of  the  tumors  situated  in  the 
pons,  medulla  oblongata  and  the  cerebellum,  we 
found  that  the  majority  were  on  the  left  side.  It 
seems,  therefore,  that  tumors  of  these  areas  are 
more  prone  to  grow  on  the  left  side. 

The  fibroma  may  be  as  small  as  a  cherry  or 


149 

the  size  of  a  large  egg.  The  growth  is  firm,  hard, 
nodular,  and  has  a  distinct  capsule  surrounding 
it.  It  is  loosely  attached  to  the  brain  by  an 
atrophic  nerve  trunk,  a  few  blood  vessels  or  a 
meningeal  process,  and  these  attachments  may 
be  easily  ruptured.  These  tumors  are  in  organic 
relation,  especially  with  the  acoustic  nerve,  and 
more  rarely  with  the  trigeminus  and  facial  nerves. 
They  nearly  always  grow  from  the  endoneurium 
and  rarely  from  the  peri-  or  epineurium.  Conse- 
quently we  may  find  medullated  nerve  fibres  either  in 
the  periphery  of  the  tumor  or  in  its  centre.  As 
a  rule,  if  the  process  involves  the  other  cranial 
nerves,  we  have  a  general  neurofibromatosis 

The  fibroma  may  undergo  a  cystic,  fatty,  or 
myxomatous  degeneration.  Very  often  in  its  ad- 
vanced stages  it  may  assume  a  sarcomatous  tend- 
ency. Histologically  we  find  a  connective  tissue 
structure  with  entire  absence  of  nerve  elements, 
except  sometimes  a  few  medullated  nerve  fibres 
either  in  the  periphery  or  its  central  part.  These 
are  remnants  of  the  nerve  on  which  the  fibroma 
grows  and  should  not  be  mistaken  for  a  part  of 
the  new  growth.  Most  writers  persist  in  call- 
ing these  tumors  neurofibromata.  The  best  ex- 
ample of  a  true  neurofibroma  is  the  amputation 
neuroma,  therefore,  a  fibroma  would  be  a  better 
term  for  these  growths. 


150 

In  a  number  of  cases  of  fibroma  of  the  acous- 
ticus  there  were  associated  cortical  changes. 
Henneberg  and  Koch  reported  hyperplasia  and 
hypertrophy  of  the  glia  cells  of  the  cortex,  espe- 
cially of  the  deeper  layer,  and  in  another  case  en- 
dothelioma and  psammomata  of  the  dura  mater. 
Fraenkel  and  Hunt  made  a  similar  observation. 
In  another  case  reported  by  these  authors  there 
were  protrusions  and  minute  hernise  attached  to 
and  sometimes  perforating  the  dura.  Histolog- 
ically, these  consisted  of  large  cells  of  the  spin- 
dle type  and  of  glia  cells. 

At  times  the  fibromatous  process  may  involve 
the  whole  of  the  intracranial  portion  of  the  acous- 
ticus.  In  a  case  of  Alexander  and  v.  Frankl- 
Hochwart,  an  anatomical  examination  of  the 
labyrinth  showed  a  degenerative  atrophy  of  the 
cochlear  nerve,  the  spiral  ganglion,  the  organ  of 
Corti,  and  the  striae  vasculares. 

These  tumors  compress  greatly  the  lateral 
lobes  of  the  cerebellum,  the  pons,  and  the  medul- 
la oblongata.  In  one  of  Dr.  Mills's  cases  the 
temporal  lobe  was  compressed.  Because  of  the 
slow  growth  and  the  nature  of  the  tumor,  clinical 
symptoms  may  not  appear  at  all,  or  only  late  in 
the  disease.  In  one  of  Dr.  Mills's  cases  there 
were  no  symptoms  of  such  a  growth,  the  tumor 
being  found  at  necropsy. 


154 

discussed  when  speaking  of  sarcoma.  Other  tu- 
mors, as  fibroma  and  carcinoma,  are  prone  to  un- 
dergo cystic  change,  but  more  rarely.  Some  au- 
thors believe  that  the  whole  tumor  may  disap- 
pear and  only  a  cyst  remain.  In  other  cases  only 
a  microscopical  examination  will  detect  a  small 
tumor  mass  in  the  walls  of  the  cyst.  Spiller  has 
pointed  out  that  the  wall  of  a  congenital  cyst 
may  be  the  starting  point  for  a  neoplasm,  and 
this  possibility  should  not  be  ignored. 

The  most  common  cystic  changes  found  in 
the  brain  are  due  to  parasitic  growth,  the  cysti- 
cercus  cellulosae  and  the  ecchinococcus.  These, 
however,  are  so  rare  in  this  country  that  they  will 
not  be  here  discussed. 

Cysts  due  to  traumatism  are  recorded,  but 
their  genesis  is  by  no  means  clear.  Congenital 
cysts  are  rare.  They  are  probably  offshoots  of 
the  primary  cerebral  vesicles.  Dermoid  cysts 
have  been  recorded  as  occurring  in  the  cerebel- 
lum in  several  instances. 

Carcinoma. — Carcinoma  of  the  cerebellum  is 
rare.  This  form  of  neoplasm  is  always  second- 
ary and  grows  from  the  dura  or  in  the  substance 
of  the  brain.  Saenger  recorded  infiltration  of  the 
cerebral  pia  with  cancer  cells.  The  possibility 
of  toxic  changes  must  be  considered,  as  it  is  not 
improbable  that  through  intoxication  caused  by 


Fig.  3. — Fibroma  growing  in  the  left  cerebellopontile  angle  com- 
pressing the  lower  surface  of  the  cerebellum  and  the  left 
side  of  the  pons. 


157 


a  carcinoma  elsewhere  in  the  body,  symptoms  of 
brain  tumor  may  be  present. 

Osteoma. — In  several  instances  an  osteoma  has 
been  described  as  occurring  in  the  cerebellum. 
It  is  probable  that  these  growths  are  not  pri- 
marily of  bone  formation,  but  are  the  result  of  cal- 
cification of  such  tumors  as  tuberculoma,  fibroma, 
sarcoma,  and  even  lipoma.  Other  neoplasms, 
as  adenoma,  lipoma,  angioma,  psammoma,  and 
cholesteatoma  are  hardly  ever  found  in  the  cere- 
bellum, so  they  will  not  be  discussed.  It  must 
also  be  remembered  that  aneurysm  of  the  verte- 
bral or  basilar  artery  may  give  symptoms  of  cere- 
bellar growth. 

The  Influence  of  Cerebellar  Growths. — At  the 
operation  when  the  dura  is  removed  there  is 
nearly  always  increased  tension  and  the  parts 
may  bulge.  The  surface  of  the  cerebellum  is 
flat  and  the  fissures  may  be  abolished.  The  pia 
covering  the  neoplasm  is  generally  poor  in  its 
blood  supply.  The  tissues  near  the  growth  may 
be  softened.  If  the  tumor  is  in  the  lateral  lobe  of 
the  cerebellum  it  may  compress  the  fifth,  seventh, 
and  eighth  cranial  nerves.  The  occipital  lobes 
may  even  be  compressed  through  the  tentorium. 
If  the  cerebellar  tumor  is  large  it  may  compress 
the  corpora  quadrigemina,  pons,  and  the  medulla 
oblongata,  and  these  structures  may  be  flattened 


158 


or  deformed.  Pressure  may  also  be  exerted  upon 
the  cranial  nerves  at  the  base  of  the  brain.  The 
influence  of  cerebellopontile  growths  upon  sur- 
rounding structures  has  already  been  discussed. 

The  cerebrospinal  fluid  is  almost  always  in- 
creased in  cases  of  cerebellar  tumor,  because 
pressure  is  exerted  upon  the  communication  be- 
tween the  lateral  ventricles  and  the  fourth  ven- 
tricle, or  upon  the  veins  of  Galen,  which  convey 
the  blood  from  the  choroid  plexus  to  the  sinus 
rectus.  Because  of  this  internal  hydrocephalus 
undue  pressure  is  brought  to  bear  upon  the  differ- 
ent cranial  nerves,  as  the  optic  and  olfactory. 
The  optic  chiasm  may  be  directly  compressed 
through  pressure  from  the  third  ventricle. 

Alterations  in  the  posterior  roots  and  the  pos- 
terior columns  of  the  spinal  cord  have  been  re- 
corded as  occurring  in  conjunction  with  tumors 
of  the  brain.  Such  changes  have  been  also  found 
by  Dr.  Spiller.  According  to  Batten  and  Collier 
they  are  especially  present  in  cerebellar  growths, 
and  are  due  to  the  increased  pressure.  Dinkier 
and  Becker  believe  that  toxic  or  nutritional 
changes  are  at  fault. 

Tumors  of  the  Fourth  Ventricle,  Medulla  Oblon- 
gata, Pons,  and  Choroid  Plexus. — It  is  not  in  the 
province  of  this  paper  to  consider  in  extenso  neo- 
plasms  of  these   areas,   but   inasmuch    as   these 


159 


growths  sometimes  give  symptoms  of  cerebellar 
involvement,  they  will  be  briefly  considered. 

Tumors  of  the  fourth  ventricle  and  of  the  me- 
dulla oblongata  may  give  no  appreciable  clin- 
ical symptoms.  They  may  either  be  cystic  or 
hard,  and  may  grow  in  the  substance  of  the  me- 
dulla oblongata.  This  is  especially  true  of  para- 
sitic and  congenital  cysts.  Hunt  recorded  two 
congenital  cysts  of  the  fourth  ventricle  in  which 
the  cerebellum  was  greatly  compressed  and  yet 
there  were  no  cerebellar  symptoms. 

Neoplasms  growing  within  or  upon  the  cor- 
pora quadrigemina  nearly  always  compress  the 
middle  or  the  lateral  lobes  of  the  cerebellum. 
They  also  cause  internal  hydrocephalus.  Two 
such  specimens  are  in  our  collection. 

Tumors  of  the  pons  may  cause  pressure  symp- 
toms upon  the  cerebellum,  or  the  growths  may 
involve  the  middle  cerebellar  peduncles.  Growths 
of  the  chorioid  plexus,  as  in  a  case  of  Arnold's, 
where  a  psammoma  of  the  size  of  an  apple  was 
found,  may  compress  the  pons,  medulla  oblon- 
gata, and  the  cerebellum. 

Tumors  in  the  Cerebrum  Giving  Symptoms  of 
Cerebellar  Growth. — Ascherson  recorded  an  in- 
stance in  which  a  sarcoma  was  found  in  the  cen- 
trum ovale  of  the  left  side  in  the  upper  motor  area. 
This  neoplasm  measured  i^  by  2^  inches,  and 


160 

could  easily  be  enucleated.  It  caused  a  compres- 
sion of  the  lateral  ventricle  in  the  same  side. 
This  author  cites  Raymond  as  having  recorded 
an  almost  similar  case.  Ascherson  is  of  the  opin- 
ion that  the  cerebellar  symptoms  were  due  to 
pressure  exerted  through  the  lateral  ventricle, 
and  he  emphasizes  the  importance  of  early  symp- 
toms before  those  of  pressure  are  apparent.  In 
this  connection  the  fact  that  tumors  of  the  post- 
parietal  cortex  or  subcortex,  may  give  unilateral 
ataxia  should  be  borne  in  mind.  The  diagnosis 
between  post  parietal  and  cerebellar  tumors  is 
given  in  the  paper  of  Dr.  Mills. 

Abscess. — Chronic  otitis  media  is  the  most  fre- 
quent cause  of  abscess  in  the  cerebellum.  It 
may  be  due  to  such  other  causes  as  traumatism 
or  may  be  a  part  of  a  general  pysemic  process, 
but  these  instances  are  uncommon.  The  abscess 
occurs  mostly  in  the  anterior  outer  part  of  the 
cerebellum,  and  is  generally  single.  It  may  in- 
volve also  the  adjoining  temporal  lobe.  The  ab- 
scess may  be  encapsulated  or  it  may  keep  on 
forming  pus.  Surrounding  it,  oedema  and  soft- 
ening of  the  brain  substance  are  found.  Pus  may 
travel  along  the  facialis  and  acousticus,  and  cause 
extradural  abscesses.  Hydrocephalus,  sinus 
thrombosis,  and  thrombophlebitis  are  frequent 
complications. 


161 


Internal  Hydrocephalus. — This  condition  is  most 
often  caused  by  a  brain  tumor,  but  it  may  be 
congenital  or  acquired.  Spiller  recorded  an  in- 
stance in  which  the  symptoms  were  those  of 
cerebellar  tumor,  and  at  the  necropsy  the  cere- 
bral ventricles  were  much  distended,  but  the 
fourth  ventricle  was  of  normal  size.  The  aque- 
duct of  Sylvius  was  almost  entirely  occluded 
when  examined,  and  the  occlusion  must  have 
been  congenital  or  have  occurred  early.  Byrom 
Bramwell  recorded  a  similar  case,  but  here  a 
localized  meningitis  caused  a  closure  of  the  fora- 
men of  Magendie.  The  possibilty  of  internal 
hydrocephalus  should  always  be  kept  in  mind 
when  a  cerebellar  growth  is  considered. 

Symptoms  of  Cerebellar  Tumor  Without  Lesions. 
— In  a  very  important  paper,  Nonne  called  atten- 
tion to  those  cases  in  which  the  majority  of  the 
symptoms  of  brain  tumor  were  present,  and  in 
which  either  spontaneously  or  under  mercurial 
treatment  the  symptoms  disappeared,  leaving, 
perhaps,  a  partial  optic  nerve  atrophy.  There 
was  no  reason  in  any  of  the  eight  clinical  cases 
he  reported  to  suspect  syphilis. 

He  also  records  three  similar  cases  with  ne- 
cropsy, in  two  of  which  symptoms  of  a  tumor  in 
the  posterior  cranial  fossa  was  diagnosticated.  At 
the  necropsy  in  the  first   case,  internal  hydro- 


162 

cephalus  was  found.  On  the  floor  of  the  fourth 
ventricle,  opposite  the  posterior  medullary  velum, 
there  was  a  hard,  long,  yellowish  white  struc- 
ture, which  obstructed  the  flow  of  the  cerebro- 
spinal fluid.  Microscopically  this  was  found  to 
be  a  fibroma.  In  his  second  case,  internal  hydro- 
cephalus was  also  found,  this  being  caused  by  a 
sarcoma  of  the  ependyma  of  the  floor  of  the 
fourth  ventricle. 

He  further  records  three  cases  with  necropsy 
in  which  there  was  no  internal  hydrocephalus. 
Nonne  also  reports  cases  of  internal  hydro- 
cephalus which  gave  largely  basal  symptoms  due 
to  various  causes,  and  which  terminated  either 
in  death  or  recovery.  He  leaves  us  in  doubt  as 
to  what  is  the  cause  of  such  a  condition. 

Dr.  Spiller  has  very  kindly  given  me  the  rec- 
ords of  such  a  case  occurring  in  his  service. 

Woman,  44  years  of  age,  domestic,  past  his 
tory  unimportant.  Two  and  one  half  years  age 
the  patient  began  to  have  violent  headache  in 
the  left  cerebellar  region.  This  headache  became 
more  severe  and  became  localized  in  the  left 
parietal  region,  where  there  was  also  great  ten- 
derness to  pressure.  She  had  an  ataxic,  drunken 
gait,  and  would  fall  to  the  left  or  backwards 
when  walking.  Extreme  vertigo  was  also  pres- 
ent, especially  when  she  was  lying  on  her  left 
side  or  walking.     Power  was  diminished  in  the 


163 

lower  limbs  and  sensation  was  also  somewhat 
impaired.  The  patellar  jerks  were  absent.  There 
was  no  albumin  in  the  urine. 

Dr.  Roberts  operated  at  the  point  of  great  ten- 
derness in  the  left  posterior  parietal  region. 
There  was  nothing  abnormal  found  and  the 
brain  appeared  to  be  in  a  healthy  condition. 

The  patient's  symptoms  steadily  disappeared, 
the  pain  in  the  head  became  better  and  in  a 
short  time  she  seemed  almost  well. 

Another  case  was  studied  by  me  repeatedly. 

This  woman  was  in  the  nervous  wards  of  the 
Philadelphia  General  Hospital  in  the  service  of 
Dr.  Spiller.  She  was  52  years  of  age,  denied 
venereal  history,  and  her  past  history  was  unim- 
portant. Five  years  ago  she  began  to  have  vio- 
lent vertical  headache,  which  has  persisted  more 
or  less  since.  One  year  ago  she  began  to  have 
objective  vertigo,  and  convulsions,  Jacksonian  in 
type,  which  always  involved  the  left  side  of  the 
face,  and  the  left  arm  and  leg.  Sight  also  became 
poor  at  that  time,  and  her  memory  was  not  as 
good  as  formerly.  In  my  examination  she 
showed  a  paresis  of  the  left  arm  and  leg,  these  be- 
ing spastic,  and  the  reflexes  were  exaggerated. 
The  Babinski  sign  was  present  on  this  side. 
There  was  also  a  paresis  of  the  lower  distribu- 
tion of  the  left  seventh  nerve,  and  a  paralysis 
of  the  left  abducens  and  the  left  fifth  nerve,  both 
in  its  motor  and  sensory  distribution.  Optic 
neuritis  was  present  in  both  eyes. 


164 

On  protruding  her  tongue  she  had  a  clonic  to 
and  fro  movement  which  became  apparent  on 
talking  or  moving  the  tongue.  She  became  stead- 
ily worse  and  finally  was  comatose.  The  urine 
examination  was  negative.  She  rallied,  however, 
her  symptoms  steadily  disappeared  and  she  was 
discharged  from  the  hospital  four  months  after- 
wards, the  only  remaining  symptom  being  a 
dimness  of  vision. 

These  two  cases  are  similar  to  those  recorded 
by  Nonne.  No  adequate  explanation  for  them 
can  be  given. 

Lesions  of  the  Cerebellum  Without  Symptoms. — 
These  lesions  may  be  either  congenital,  acquired 
early  in  life,  or  may  be  tumors.  It  is  not  sur- 
prising that  injuries  to  the  cerebellum  early  in 
life  or  that  tumors  of  slow  development  which 
occur  in  the  same  period  give  no  appreciable 
symptoms,  because  the  functions  of  the  cerebel- 
lum in  such  cases  have  probably  been  assumed 
by  other  parts  of  the  brain.  Lesions  of  the  lat- 
eral lobes  of  the  cerebellum  are  less  liable  to 
cause  symptoms  than  when  the)''  implicate  the 
entire  cerebellum.  Spiller  recorded  three  cases 
of  lesion  of  the  cerebellum  in  which  there  were 
no  symptoms,  and  he  also  reviewed  the  litera- 
ture upon  this  subject.  In  his  first  case  one  cere- 
bellar lobe  was  smaller  than  the  other,  and  it  was 
sclerotic.     In  the  second  case  there  was  a  tumor 


165 

upon  the  corpora  quadrigemwia  in  which  the  lat- 
eral lobe  of  the  cerebellum  was  compressed.  The 
third  was  one  of  tumor  within  the  vermis. 

Cases  are  recorded  in  which  tubercles  in- 
volved an  entire  lateral  lobe  and  gliomata  and 
cysts  occupied  the  middle  lobe,  and  yet  there 
were  no  symptoms.  Oppenheim  refers  to  a  case 
of  Putnam's,  where  the  only  symptom  for  years 
was  an  optic  nerve  atrophy,  in  which  at  necropsy 
a  cyst  of  the  cerebellum  was  found.  He  also  re- 
fers to  Bramwell's  case,  where  in  a  thoroughly 
studied  case  no  symptoms  were  apparent,  while 
at  necropsy  four  tumors  were  found. 

It  can  readily  be  understood  why  symptoms 
may  not  be  apparent  in  a  gliomatous  tumor,  be- 
cause of  its  infiltrating  character,  and  in  tuber- 
cles, in  which  the  axis  cylinders  are  retained ;  but 
it  is  difficult  to  explain  the  absence  of  symptoms 
in  the  other  instances. 

The  notes  of  the  case  of  cerebellopontile  tumor, 
as  shown  in  the  illustration.  Fig.  3,  and  Case  II  of 
this  paper,  were  furnished  by  Dr.  Mills.  The  pa- 
tient was  seen  by  Dr.  Mills  in  consultation  with 
Dr.  W.  W.  Keen ;  she  was  also  examined  in  con- 
sultation by  Dr.  W.  G.  Spiller.  The  tumor  sprang 
from  the  eighth  nerve,  and  the  chief  focal  symptoms 
were  one  sided  deafness,  tinnitus,  facial  monospasm, 
hypsesthesia  of  one  side  of  the  face,  nystagmoid 


166 


movements,  slight  paresis  of  right  abducens,  and 
vasomotor  and  cardiac  disturbances.  Severe 
headache,  nausea,  vomiting,  and  optic  neuritis 
were  also  present. 

This  patient  was  a  married  woman,  30  years 
of  age,  five  of  whose  maternal  relatives  had  died 
of  cancer.  Four  years  before  coming  under  ob- 
servation the  ossicles  of  her  left  ear  were  re- 
moved, on  account  of  an  annoying  tinnitus,  but 
without  the  desired  result.  About  one  year  later 
she  began  to  suffer  from  severe  headache.  The 
next  year  slight  optic  neuritis  was  observed  in 
both  eyes,  the  neuritis  going  on  to  atrophy  and 
blindness,  which  was  complete  in  less  than  two 
years.  Headache,  nausea,  vomiting,  and  depres- 
sion were  recurring  symptoms,  and  taste  and 
smell  were  impaired.  During  two  or  three  years 
she  was  treated  for  various  complaints  as  anaemia 
and  neurasthenia,  and  both  Graves's  disease  and 
interstitial  nephritis  were  suspected.  About  six 
months  before  coming  under  observation  she 
had  a  convulsion  with  loss  of  consciousness,  this 
being  followed  by  several  others  of  a  similar 
kind. 

The  patient  was  having  at  somewhat  frequent 
intervals  attacks  beginning  with  pain  in  the  head, 
which  was  referred  to  the  forehead  and  eyes..  In 
these  she  became  nauseated  and  then  vomited, 
becoming  pale  or  even  cyanosed,  with  loss  of 
consciousness.  The  vomiting  was  preceded  or 
accompanied  by  marked    facial   monospasm,   in 


167 

which  the  mouth  was  drawn  forcibly  to  the  left 
and  the  eyelids  were  drawn  together.  Only  the 
left  side  of  the  face  was  involved  in  the  seizure. 
Examination  showed  that  she  had  no  ataxia  of 
station  or  gait.  Hearing  on  the  right  side  was 
good,  on  the  left  side  it  was  abolished.  The 
mouth  deviated  slightly  to  the  left  when  opened 
widely.  Hypassthesia  to  pain  was  present  on  the 
left  side  of  the  face  and  head,  and  sometimes  ap- 
peared to  be  present  in  the  left  hand.  The  pa- 
tient was  not  mentally  impaired,  but  was  easily 
exhausted  mentally,  and  was  at  times  irritable 
and  depressed  as  the  result  of  her  sufferings. 
During  the  time  she  was  under  observation  she 
had  frequently  recurring  headaches,  usually  se- 
vere, sometimes  accompanied  with  nausea  or  even 
vomiting,  and  sometimes  with  the  facial  spasm 
already  described.  Irregular  nystagmoid  move- 
ments occurred  when  the  patient  turned  the  eye- 
balls to  the  extreme  right  or  left.  She  had  com- 
plete loss  of  smell,  and  loss  of  taste  on  the  left 
side  of  the  tongue.  On  one  occasion  it  was 
thought  that  the  facial  spasm  was  accompanied 
by  some  spasmodic  movements  of  the  left  hand, 
but  this  was  doubtful,  and  even  the  observer 
thought  it  may  have  been  a  voluntary  movement. 
The  question  of  the  existence  of  exophthalmic 
goitre  was  one  which  arose  for  diagnostic  dis- 
cussion several  times  during  the  history  of  this 
case.  The  diagnosis  of  this  affection  was  first 
made  a  year  or  two  before  coming  under  our  ob- 
servation. It  was  also  considered  and  favorably 
regarded  by  some  of  those  who  saw  her  in  con- 


168 

sultation  late  in  the  case.  Her  eyes  had  some- 
what the  staring  expression  of  the  blind;  they 
were  rather  large,  but  her  relatives  stated  that 
she  had  always  had  prominent  eyes,  and  the  ex- 
ophthalmos was  apparent  rather  than  real.  The 
enlargement  of  the  thyreoid  was  so  doubtful  as 
to  cause  some  disagreement  among  those  who 
examined  her  as  to  its  existence.  A  slight  en- 
largement of  the  gland  on  one  side  seemed  some- 
times to  be  present.  Her  pulse  frequently,  per- 
haps usually,  was  between  loo  and  no,  and  some- 
times rose  above  the  latter  point.  It  was  a  pulse 
such  as  is  not  infrequently  seen  in  the  late  stages 
of  an  exhaustive  intracranial  disease.  Graves's 
disease  was  finally  excluded.  In  the  light  of  the 
post  mortem  findings,  it  is  not  improbable  that 
some  of  the  symptoms  simulating  this  affection 
were  due  to  the  tumor,  from  its  position,  causing 
vasomotor  and  cardiac  disturbances. 

Ocular  and  ophthalmoscopic  examinations 
were  made  by  Dr.  W.  C.  Posey,  who  reported 
as  follows:  Ocular  movements  good  in  all  direc- 
tions, except  externally  to  the  right,  where  there 
is  a  slight  limitation  of  movement,  the  right  eye 
not  being  brought  as  far  as  normal  into  the  ex- 
ternal canthus.  On  fixation  in  the  median  line 
and  below,  the  eyeballs  are  quiet.  Marked  lat 
eral  nystagmic  movements  appear,  however,  as 
soon  as  the  eyes  leave  these  primary  positions, 
the  nystagmus  being  most  marked  on  extreme 
outward  rotation  to  the  right  and  to  the  left. 
The  pupil  in  the  right  eye  is  round,  and  is  5  mm. 
in  size;  that  in  the  left  eye  is  oval,  3  by  4  mm., 


169 

with  its  long  axis  at  50°.  The  irides  do  not 
respond  to  light  or  accommodation  stimuli.  The 
ophthalmoscopic  examination  reveals  clear  media 
in  each  eye,  with  the  signs  of  regressive  optic 
neuritis.  The  swelling  of  the  nerves,  however, 
is  still  very  marked,  both  papillae  projecting  into 
the  fundi  to  the  extent  of  2  or  3  mm.  The 
nerves  are  gray  and  succulent  looking,  and  the 
retinal  arteries  and  veins  are  tortuous  and  cord 
like.  One  nerve  is  not  more  swollen  than  the 
other.  There  are  no  extravasations  or  haemor- 
rhages, or  traces  of  either  of  these  in  the  fundi. 
The  patient  is  totally  blind. 

Other  examinations  were  made  by  Dr.  Posey, 
but  they  did  not  demonstrate  anything  different 
from  what  is  above  recorded. 

Eventually  an  operation  was  performed  in  this 
case  by  Dr.  W.  W.  Keen,  by  whom  the  patient 
was  seen  in  consultation  with  Dr.  Mills.  Al- 
though a  tumor  at  the  base  was  considered,  it  was 
thought  for  several  reasons  that  the  lesion  was 
probably  in  or  beneath  the  facial  centre.  In  the 
first  place  sufficient  consideration  was  not  given 
to  the  tinnitus  and  deafness.  Owing  to  the  fact 
that  a  peripheral  operation  had  been  performed 
early  for  the  relief  of  the  latter,  it  was  supposed 
that  the  impairment  and  disturbance  of  hearing 
were  due  to  causes  which  were  at  least  in  part 
peripheral.  The  facial  monospasm  was  much  like 
that  which  is  observed  in  the  case  of  subcortical 
or  cortical  growth.  It  is  interesting  to  note  that 
some  disease  of  the  cortex  was  present  at  the 
position  of  the   trephining,  as   demonstrated  at 


170 

the  necropsy,  but  no  tumor  was  found  here.    The 
patient  died  a  few  hours  after  the  operation. 
Bibliography. 

Schuster.  Psychische  Storungen  bei  Hirntumoren,  Stutt- 
gart, 1902. 

Raubitschek.  Wiener  klin.  Wochenschrift,  September  29, 
1904. 

Oppenheim.  Die  Geschwiilste  des  Gehirns,  Wien,  1902, 
page  6. 

Spiller.  American  Jour,  of  the  Med.  Sci.,  February,  1904, 
page  16. 

Spiller.    American  Jour,  of  the  Med.  Sci.,  July,  1903. 

Mills.  University  of  Pennsylvania  Med.  Bulletin,  May, 
1904. 

Henneberg  and  Koch.  Archiv.  f.  Psychiatric,  Vol. 
XXXVI,  No  I,  page  51. 

Fraenkel  and  Hunt.    Medical  Record,  December  26,  1903. 

Alexander  and  v.  Frankl-Hochwart.  Obersteiner's  Ar- 
beiten,  Vol.  XI,  1904,  page  385. 

Spiller.  University  of  Pennsylvania  Med.  Bulletin,  June, 
1901,  page  13. 

Saenger.    Neurolog.  Centralblatt,  1901,  page  188. 

Batten  and  Collier.    Brain,  1899. 

Dinkier.    Zeitschrift  fUr  Nervenheilk.,  Vol.  VI. 

Hunt.    American  Jour,  of  the  Med.  Sci.,  March,  1904. 

Ascherson.    Lancet,  September  10,  1904,  page  759. 

Spiller.    American  Jour,  of  the  Med.  Sci.,  July,  1902. 

Bramwell.    Brain,  Spring,  1899,  Vol.  XXII,  page  66. 

Nonne.  Deutsche  Zeitschrift  fUr  Nervenheilk.,  Vol. 
XXVII,  Nos.  3  and  4. 

Spiller.  University  of  Pennsylvania  Med.  Bulletin,  June, 
1904. 

Oppenheim.    Loc.  cit.,  page  156. 


THE  FUNCTIONS  OF  THE  CEREBELLUM. 
By  EDWARD  LODHOLZ,  M.  D., 

PHILADELPHIA, 
DEMONSTRATOR  OF  PHYSIOLOGY,  UNIVERSITY  OF  PENNSYLVANIA. 

Probably  there  is  no  part  of  the  nervous  system 
that  differs  more  in  size  and  functional  importance, 
in  closely  allied  species,  than  the  cerebellum.  Its 
development  depends  to  a  great  extent  upon  the 
means  of  orientation  of  the  animal.  Reptiles  pos- 
sess a  cerebellum  functionally  less  active  than 
swimmers,  and  in  these  it  is  less  developed  than  in 
birds.  Indeed  in  this  animal  which  is  capable  of 
going  through  the  most  complicated  movements  of 
all  animals  the  cerebellum  is  relatively  enormous. 
However,  the  size  is  not  always  proportionate  to 
the  variety  of  movements.  In  the  frog,  which  is 
capable  of  complex  coordination,  the  cerebellum  is 
relatively  small.  It  is  an  unexplained  anatomical 
fact  that  in  birds  the  lateral  lobes  are  absent,  where- 
as in  apes  and  man  they  are  quite  large. 

Possibly  no  one  has  given  so  much  impetus  to 
the  study  of  this  part  of  the  nervous  system  as 
Flourens  ( i ) ,  Practically  all  his  experiments  were 
performed  upon  pigeons,  animals  which  show 
marked  effects  following  the  removal  of  parts  of 
the  cerebellum.    Many  of  the  phenomena  here  ob- 


172 

served  can  be  of  but  comparative  interest  to  the 
student  of  human  physiology.  For  this  reason  the 
work  of  Luciani  has  done  much  to  further  our 
knowledge  of  the  function  of  the  human  cerebellum. 
He  experimented  upon  dogs  and  monkeys,  animals 
in  which  the  cerebellum  is  more  closely  allied  to  the 
human  cerebellum  than  that  of  pigeons. 

So  early  as  1809  Rolando  (2)  removed  portions 
of  the  dog's  cerebellum,  and  several  other  physiol- 
ogists studied  the  mammalia  previous  to  Luciani's 
time,  but  none  was  able  to  surmount  the  tremen- 
dous technical  difficulties  necessary,  for  instance,  to 
remove  the  whole  cerebellum  and  keep  the  animal 
alive  for  a  considerable  period  after  the  opera- 
tion. 

Luciani  (3)  showed  the  immediate  symptoms 
differed  very  much  from  those  which  subsequently 
developed.  If  the  narcosis  is  not  too  deep,  and  the 
loss  of  blood  inconsiderable,  the  more  important 
symptoms  which  immediately  follow  removal  of  the 
cerebellar  cortex,  are  extreme  restlessness  ;  pleuro- 
thotonos,  the  concavity  being  toward  the  operated 
side;  tonic  stretching  of  the  fore  extremity  on  the 
homonymous  side ;  clonic  contractions  of  the  other 
three  extremities ;  and  spiral  twisting  of  the  neck 
with  the  head  turned  toward  the  well  side.  Nystag- 
mus and  strabismus  are  present,  the  eye  of  the 
side  operated  upon  being  drawn  down  and  inward, 


173 

that  of  the  well  side  up  and  out.  If  the  animal  at- 
tempts to  stand,  he  falls  to  the  side  of  the  lesion 
and  rolls  in  the  same  direction. 

When  the  whole  cerebellum  is  removed  there  is 
marked  restlessness  and  irritability  of  the  animal; 
the  head  is  drawn  back,  and  the  animal  tends  con- 
stantly to  move  or  fall  backwards.  There  is  con- 
vergence of  the  eyeballs.  If  the  wound  remains 
aseptic  these  symptoms  last  from  eight  to  ten  days 
when  they  generally  ameliorate,  the  tonic  spasms 
become  clonic  or  oscillatory,  the  animal  is  able 
to  walk  with  less  difficulty,  and  the  tendency  to  roll 
from  side  to  side  or  fall  backward  is  less  marked. 
Long  before  the  animal  learns  to  walk  he  is  able  to 
swim.  This  fact,  first  described  by  Luciani,  has 
great  physiological  importance.  The  last  symptom 
to  disappear  is  opisthotonos. 

The  symptoms  which  occur  with  constancy  after 
removal  of  the  cerebellum  give  us  but  little  infor- 
mation as  to  the  exact  role  this  part  of  the  nervous 
system  plays  in  the  intact  cerebrospinal  axis. 
Wundt  states  that  "  the  functions  of  the  cerebellum 
belong  to  the  darkest  part  of  the  central  nervous 
system."  The  truth  of  this  statement  becomes  more 
apparent  when  the  multitudinous  connections  of  the 
cerebellum  with  other  portions  of  the  brain  and 
spinal  cord  are  considered. 

The  old  idea  that  the  cerebellum   has   distinct 


174 

functions  independent  of  its  connection  with  the 
rest  of  the  cerebrospinal  axis  is  rapidly  disappear- 
ing. 

The  centre  for  coordination  has  been  located  in 
the  cerebellum  by  Flourens,  and  the  symptoms 
which  follow  ablation  of  a  part,  or  the  whole  of  the 
cerebellum  seem  to  substantiate  this  assertion.  How- 
ever, cases  have  been  recorded  in  which  a  large 
portion  was  congenitally  absent  associated  with 
normal  ability  to  execute  coordinate  movements. 

Total  ablation  in  animals  is  always  followed  by 
an  amelioration  of  the  symptoms  after  varying  in- 
tervals of  time,  and  eventually  incoordination  en- 
tirely disappears. 

When  the  cerebellum  is  inactive  it  appears  that 
cells  in  other  parts  of  the  nervous  system  are 
capable  of  performing  the  functions  normally  as- 
signed to  the  cerebellar  cells.  The  experiments  of 
Ewald  (4)  and  Luciani  confirm  this  statement. 
They  demonstrated  that  if  compensation  was  com- 
pletely established  after  partial  cerebellar  destruc- 
tion, a  return  of  symptoms  would  appear  if  certain 
cerebral  motor  areas  were  destroyed.  The  symp- 
toms never  reappear  after  the  second  operation. 

A  close  functional  relation  has  been  found  to  exist 
between  the  semicircular  canals  and  the  cerebellum. 
Total  destruction  of  the  canals  is  followed  by  symp- 
toms identical  with  cerebellar  ablation.    Stef ani  ( 5  ) 


175 

found  degeneration  of  Perkinje's  cerebellar  cells 
after  removal  of  the  semicircular  canals.  From 
this  the  inference  may  be  drawn  that  the  canals  are 
the  peripheral  organs  and  the  cerebellum  is  the 
centre.  Lange,  a  student  of  Ewald,  found  when 
the  semicircular  canals  were  removed  from  a  de- 
cerebellarized  animal,  in  which  full  compensation 
had  been  established,  that  the  characteristic  symp- 
toms appeared  such  as  are  observed  in  a  normal 
animal  following  destruction  of  the  canals.  Stefani 
concludes  that  the  semicircular  canals  functionate 
not  only  through  the  cerebellum,  but  also  through 
other  parts  of  the  nervous  system.  Luciani  thinks 
these,  and  other  experiments,  disprove  the  belief  of 
Magendie  (6)  that  the  cerebellum  is  the  centre  of 
static  and  dynamic  equilibrium.  He  believes  it  does 
play  an  important  role  in  the  maintenance  of  equili- 
brium, and  agrees  with  Galio  (7)  that  we  move  in 
space  by  the  aid  of  impulses  coming  from  the  special 
senses. 

The  results  obtained  from  excitation  of  the  cere- 
bellar surfaces  have  added  to  some  extent  to  our 
knowledge  of  the  influence  of  the  cerebellum  upon 
nervous  activity.  It  is  a  mooted  question  whether 
ablation  produces  symptoms  the  result  of  stimulation 
consequent  to  the  trauma  of  the  operation,  or  pa- 
ralysis due  to  destruction  of  the  cells.  Ferrier  (8) 
showed  that  unilateral  burning  of  the  cerebellum 


176 

produced  symptoms  on  the  opposite  side  of  the 
body  to  those  following  ablation.  But  this  method 
is  unscientific,  for  it  is  impossible  to  determine 
whether  symptoms  are  due  to  stimulation  or  de- 
pression. 

Electrical  stimulation  properly  applied  eliminates 
depression  as  a  factor.  A  recent  work  by  Lewan- 
dowsky  (9)  has  shown  that  the  electrical  current 
produces  results  differing  from  those  following 
ablation.  When  weak  currents  were  applied  to  the 
cerebellum  the  following  symptoms  were  noted: 
Restlessness;  evidences  of  vertigo;  lateral  move- 
ments of  the  head ;  or  the  animal  assumed  a  recum- 
bent position  and  placed  the  head  between  the  front 
paws.  Strong  currents  caused  curvature  of  the 
spinal  column,  when  the  left  side  was  stimulated 
the  concavity  was  toward  the  right  side,  the  dog 
always  fell  toward  the  right.  Occasionally  nystag- 
mus was  observed.  When  the  current  was  broken 
the  movements  occurred  on  the  other  side,  but  were 
decidedly  weaker.  It  will  be  noticed,  as  Lewan- 
dowsky  states,  that  the  symptoms  following  stimu- 
lation are  on  the  opposition  side  of  the  body  to  that 
produced  by  ablation. 

Sherrington  (10)  reports  a  very  interesting 
phenomenon  following  stimulation  of  the  cerebellum. 
He  discovered  in  decerebrate  rigidity,  a  condition 
of  long  maintained  muscular  contraction  following 


177 

removal  of  the  cerebral  hemispheres,  that  inhibition 
can  be  produced  by  excitation  of  the  anterior  (cere- 
bral) surface  of  the  cerebellum.  He  demonstrated 
that  faradaization  caused  a  relaxation  of  the  muscles 
of  the  neck,  head,  and  lower  limbs,  especially  on  the 
same  side.  He  concludes  that  stimulation  of  the 
cerebellum  "  cannot  only  excite  contraction  of  the 
muscles,  but  can  inhibit  contraction."  However, 
the  exhaustive  studies  in  cerebellar  ablation  and 
stimulation  have  not  given  us  very  satisfactory 
knowledge  of  how  this  organ  normally  functionates, 
although  many  errors  have  been  corrected  and  new 
facts  added. 

The  teaching  of  the  Gall  school  that  the  cerebel- 
lum has  a  sexual  function  has  been  disproved  by 
Bouillaud,  Luciani,  and  others.  These  investiga- 
tors demonstrated  that  impregnation  and  birth  of 
offspring  would  occur  in  an  animal  from  which  the 
whole  cerebellum  was  removed. 

Flourens  was  the  first  to  locate  in  the  cerebellum 
the  centre  for  coordinated  movements. 

Luciani  demonstrated  that  coordinated  move- 
ments returned  in  animals  from  which  the  cerebel- 
lum had  been  removed. 

The  teaching  of  Rolando  that  the  cerebellum  was 
essentially  motor  has  been  modified  by  Dalton  ( 1 1 ) , 
Luys  (12),  Mitchell  (13),  and  Luciani.  These  au- 
thors consider  it  an  organ  in  which  motor  impulses 


178 

are  strengthened.  Removal  of  the  organ  causes 
muscular  weakness,  which  was  described  by 
Luciani  as  due  to  three  factors:  Asthenia  (weaken- 
ing of  muscular  energy),  atonia  (lessening  of  mus- 
cular tone),  and  astasia  (uncertain  and  unsteady 
movements). 

That  asthenia  is  present  is  shown  by  the  fact  that 
animals  with  unilateral  ablation  swim  toward  the 
crossed  side,  but  walk  toward  the  same  side. 
Astasia  is  represented  by  the  intention  tremor  which 
develops  at  varying  lengths  of  time  after  removal 
of  either  part  or  whole  of  the  cerebellum.  Atonia 
can  be  readily  detected  by  the  feebleness  of  the 
muscles  which  becomes  manifest  after  the  disappear- 
ance of  the  primary  spasm. 

Many  physiologists  have  defended  the  theory  of 
Lussana  (14)  that  the  centre  for  muscle  sense  is 
located  in  the  cerebellum.  The  vertigo  frequently 
present  suggests  a  sensory  function.  But  human 
beings  with  atrophy  of  the  cerebellum  still  possessed 
a  normal  amount  of  muscle  sense.  Luciani's  care- 
ful work  has  gone  far  to  disprove  the  existence 
of  such  a  centre  in  the  cerebellum.  The  the- 
ories advanced  to  explain  the  normal  func- 
tions seem  too  inadequate  to  account  for  all  the 
phenomena.  It  appears  conclusive  that  the  cere- 
bellar cells  are  continually  exerting  an  influence 
upon  other  nerve  centres,  but  with  reference  to  the 


179 

true  nature  of  this  action  nothing  is  known  with 

certainty. 

References. 

1.  Flourens,  Recherches  experimentales  sur  les  proprie- 
tes  et  les  fonctions  du  systeme  nerveux,  Paris,  1824  and 
1842. 

2.  Rolando,  Saggio  sopra  la  vera  struttura  del  cervelle, 
Turin,  1823. 

3.  Luciani,  Ergebnisse  der  Physiologie  (Asher  and 
Spiro),  1904,  2  Abth,  s.  260. 

4.  Ewald,  Untersuchungen  uher  den  Endorgan  des  N. 
octavus,  Wiesbaden,  1892. 

5.  Stefani,  Arch.  ital.  di  biol.,  XXX,  2,  page  235. 

6.  Magendie,  Precis  elementaire  de  physiologie,  Paris, 
1823. 

7.  Galio,  Arch.  ital.  di  biol.,  XXXVIII,  3,  page  383. 

8.  Ferrier,  see  Luciani,  Biol.  Zentralbl,  XV,  9  and  10. 

9.  Lewandowsky,  Arch.  f.  Anat.  und  Phys.,  phys.  Abth., 
1903,  page  132. 

10.  Sherrington,  Jour,  of  Phys.,  Vol.  XXII,  page  319. 

11.  Dalton,  Amer.  Jour,  of  the  Med.  Sci.,  1861,  page  83. 

12.  Luys,  Arch,  gener.  de  mid.,  1864,  page  385. 

13.  Weir  Mitchell,  Amer.  Jour,   of  the  Med.  Sci.,  1869, 
page  320. 

14.  Lussana,  Jour,  de  la  physiologie,  1862,  page  418. 

A  complete  bibliography  of  this  subject  is  given  by 
Luciani,  Ergebnisse  der  Phys.  (Asher  and  Spiro),  1904, 
s.  210. 


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